Provider Demographics
NPI:1669052742
Name:BENNETT, DIANNE (PHD)
Entity type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 T G LEE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-4409
Mailing Address - Country:US
Mailing Address - Phone:917-379-0032
Mailing Address - Fax:
Practice Address - Street 1:5850 TG LEE BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822
Practice Address - Country:US
Practice Address - Phone:407-375-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55454OtherXX