Healthcare Provider Details

I. General information

NPI: 1104701010
Provider Name (Legal Business Name): CHAD M BENNETT LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 MAPLETON AVE APT B
BOULDER CO
80304-4244
US

IV. Provider business mailing address

1510 MAPLETON AVE APT B
BOULDER CO
80304-4244
US

V. Phone/Fax

Practice location:
  • Phone: 720-808-3756
  • Fax:
Mailing address:
  • Phone: 720-808-3756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0013978
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: