Healthcare Provider Details

I. General information

NPI: 1457577785
Provider Name (Legal Business Name): LISA COHEN BENNETT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 VILLAGE CENTER DRIVE SUITE #2
LAFAYETTE CA
94549
US

IV. Provider business mailing address

919 VILLAGE CENTER DRIVE SUITE #2
LAFAYETTE CA
94549
US

V. Phone/Fax

Practice location:
  • Phone: 510-528-4718
  • Fax: 510-528-4718
Mailing address:
  • Phone: 510-528-4718
  • Fax: 510-528-4718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY12867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: