Provider Demographics
NPI:1962490474
Name:BENNETT, ROBERT TODD (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TODD
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1755 WESTGATE DR
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7174
Mailing Address - Country:US
Mailing Address - Phone:208-373-0790
Mailing Address - Fax:208-373-0816
Practice Address - Street 1:1755 WESTGATE DR
Practice Address - Street 2:SUITE 260
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7174
Practice Address - Country:US
Practice Address - Phone:208-373-0790
Practice Address - Fax:208-373-0816
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-411103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00010031804OtherREGENCE BLUE SHIELD
IDN5491OtherBLUE CROSS
ID1550229Medicare PIN