Healthcare Provider Details

I. General information

NPI: 1750904736
Provider Name (Legal Business Name): COLIN BENNETT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 S POWER RD STE 100
MESA AZ
85206-3740
US

IV. Provider business mailing address

1234 S POWER RD STE 100
MESA AZ
85206-3740
US

V. Phone/Fax

Practice location:
  • Phone: 602-633-5032
  • Fax:
Mailing address:
  • Phone: 602-633-5032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-23194
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: