Provider Demographics
NPI:1780766774
Name:BENNETT, MARCIA ANN (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:ANN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:366 SELBY AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1880
Mailing Address - Country:US
Mailing Address - Phone:651-665-0553
Mailing Address - Fax:651-665-0551
Practice Address - Street 1:366 SELBY AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1880
Practice Address - Country:US
Practice Address - Phone:651-665-0553
Practice Address - Fax:651-665-0551
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP3306103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical