Healthcare Provider Details

I. General information

NPI: 1689713802
Provider Name (Legal Business Name): JANICE O. BENNETT PHD.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 W 72ND ST SUITE 1C
NEW YORK NY
10023-2817
US

IV. Provider business mailing address

260 W 72ND ST SUITE 1C
NEW YORK NY
10023-2817
US

V. Phone/Fax

Practice location:
  • Phone: 212-787-5110
  • Fax: 212-854-9473
Mailing address:
  • Phone: 212-787-5110
  • Fax: 212-854-9473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number010327
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: