Provider Demographics
NPI:1932571775
Name:BENNETT, MARTHA ANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANNE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 5TH AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-7606
Mailing Address - Country:US
Mailing Address - Phone:908-248-2606
Mailing Address - Fax:
Practice Address - Street 1:236 5TH AVE STE 404
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7606
Practice Address - Country:US
Practice Address - Phone:908-248-2606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021421103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical