Healthcare Provider Details

I. General information

NPI: 1134302722
Provider Name (Legal Business Name): KELLY RANDOLPH BENNETT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

578 VIA ARISTA
SANTA FE NM
87506-4507
US

IV. Provider business mailing address

PO BOX 9880
SANTA FE NM
87504-9880
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-1862
  • Fax: 505-466-9459
Mailing address:
  • Phone: 505-577-1862
  • Fax: 505-466-9459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLPCC 0088061
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberMFC 2017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: