Provider Demographics
NPI:1982675203
Name:BENNETT, ELIZABETH LIBBY F (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH LIBBY
Middle Name:F
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 E KINGSLEY ST STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7228
Mailing Address - Country:US
Mailing Address - Phone:417-882-4110
Mailing Address - Fax:417-882-4155
Practice Address - Street 1:1320 E KINGSLEY ST STE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804
Practice Address - Country:US
Practice Address - Phone:417-882-4110
Practice Address - Fax:417-882-4155
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01576103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496984816Medicaid
MO496984816Medicaid