Provider Demographics
NPI:1457697302
Name:BENNETT, COURTNEY PAUL JR
Entity Type:Individual
Prefix:MR
First Name:COURTNEY
Middle Name:PAUL
Last Name:BENNETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 BRIDGE ST
Mailing Address - Street 2:STE 230
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1759
Mailing Address - Country:US
Mailing Address - Phone:781-320-7607
Mailing Address - Fax:781-326-4654
Practice Address - Street 1:280 BRIDGE ST
Practice Address - Street 2:STE 230
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1759
Practice Address - Country:US
Practice Address - Phone:781-320-7607
Practice Address - Fax:781-326-4654
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator