Healthcare Provider Details

I. General information

NPI: 1265048417
Provider Name (Legal Business Name): MARISSA L BENNERS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 COLORADO BLVD STE 102
DENTON TX
76210-6872
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 940-484-4311
  • Fax: 940-484-5075
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number38197
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: