Provider Demographics
NPI:1982734489
Name:BENNETT, ELIZABETH ADA (PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ADA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:H
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1240 E ONTARIO AVE
Mailing Address - Street 2:SUITE 102-202
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881
Mailing Address - Country:US
Mailing Address - Phone:951-283-6635
Mailing Address - Fax:951-278-8828
Practice Address - Street 1:1411 S RIMPAU AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881
Practice Address - Country:US
Practice Address - Phone:951-283-6635
Practice Address - Fax:951-278-8828
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16715103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP16715AMedicare ID - Type Unspecified