Provider Demographics
NPI:1770578908
Name:BENNETT, PHILIP R (PSYD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:R
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 1:10 BOULDER CRESCENT ST
Mailing Address - Street 2:SUITE 203A
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3344
Mailing Address - Country:US
Mailing Address - Phone:719-440-2330
Mailing Address - Fax:715-260-0779
Practice Address - Street 1:10 BOULDER CRESCENT ST
Practice Address - Street 2:SUITE 203A
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3344
Practice Address - Country:US
Practice Address - Phone:719-440-2330
Practice Address - Fax:715-260-0779
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2622103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical