Provider Demographics
NPI:1962489153
Name:BENNISON, WILLIAM M (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:M
Last Name:BENNISON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 452
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-0452
Mailing Address - Country:US
Mailing Address - Phone:631-928-9112
Mailing Address - Fax:631-928-1960
Practice Address - Street 1:1 HIGH PATH
Practice Address - Street 2:HOPE HOUSE
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1276
Practice Address - Country:US
Practice Address - Phone:631-928-9112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006877103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00696231Medicaid
NYA300023219Medicare PIN