Provider Demographics
NPI:1649637398
Name:BENNETT, STEVEN BRYCE (PSYD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:BRYCE
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 S ALMA SCHOOL RD
Mailing Address - Street 2:SUITE A216
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-3064
Mailing Address - Country:US
Mailing Address - Phone:480-282-4237
Mailing Address - Fax:623-900-7217
Practice Address - Street 1:1930 S ALMA SCHOOL RD
Practice Address - Street 2:SUITE A216
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3064
Practice Address - Country:US
Practice Address - Phone:480-282-4237
Practice Address - Fax:623-900-7217
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTL-4103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical