Provider Demographics
NPI:1740489426
Name:BENNETT, ROBERT TELFORD (BS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:TELFORD
Last Name:BENNETT
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3809 HERITAGE TRL
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1047
Mailing Address - Country:US
Mailing Address - Phone:580-481-0198
Mailing Address - Fax:
Practice Address - Street 1:116 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-4295
Practice Address - Country:US
Practice Address - Phone:866-926-6552
Practice Address - Fax:580-547-4076
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst