Healthcare Provider Details

I. General information

NPI: 1891900098
Provider Name (Legal Business Name): HENRI EDWARD BENNETTE PSYCHOLOGY/BEHAVIORA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: HENRY EDWARD BENNETT PSYCHOLOGY

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 08/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PMB462 STE A 231 E. ALESSANDRO BLVD SUITE A
RIVERSIDE CA
92508-0000
US

IV. Provider business mailing address

3933 10TH ST
RIVERSIDE CA
92501
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-0842
  • Fax: 951-955-8542
Mailing address:
  • Phone: 951-328-2283
  • Fax: 651-684-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number260-426-7234
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: