Healthcare Provider Details

I. General information

NPI: 1861590705
Provider Name (Legal Business Name): BENNETT I TITTLER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BOSTON ST
LYNN MA
01904-2540
US

IV. Provider business mailing address

47 CROSMAN AVE
SWAMPSCOTT MA
01907-1412
US

V. Phone/Fax

Practice location:
  • Phone: 781-599-3109
  • Fax: 781-599-3162
Mailing address:
  • Phone: 781-581-9547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3194
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: