Healthcare Provider Details

I. General information

NPI: 1679513683
Provider Name (Legal Business Name): THOMAS S BENNETT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 GOVERNMENT BLVD STE 203
MOBILE AL
36693-4310
US

IV. Provider business mailing address

PO BOX 1160
ORANGE BEACH AL
36561-1160
US

V. Phone/Fax

Practice location:
  • Phone: 251-300-7134
  • Fax: 251-202-7851
Mailing address:
  • Phone: 251-928-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number336
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: