Healthcare Provider Details

I. General information

NPI: 1962461780
Provider Name (Legal Business Name): THOMAS L BENNETT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 ROBERTSON ST
FORT COLLINS CO
80524-3926
US

IV. Provider business mailing address

213 CAMINO REAL
FORT COLLINS CO
80524-8907
US

V. Phone/Fax

Practice location:
  • Phone: 970-493-6667
  • Fax: 970-493-8016
Mailing address:
  • Phone: 970-493-6667
  • Fax: 970-493-8016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number895
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: