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General NPI Number Information
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NPI Number | 1134302722
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Entity Type | Individual
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Provider Name | KELLY RANDOLPH BENNETT PHD
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Gender | Male
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Dates
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Enumeration Date | 12/06/2007
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Last Update Date | 04/07/2008
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Provider Practice Location Address
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Address Line | 578 VIA ARISTA
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City | SANTA FE
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State | NM
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Zip | 87506-4507
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Country | US
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Telephone | 505-577-1862
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Fax | 505-466-9459
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Provider Business Mailing Address
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Address Line | PO BOX 9880
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City | SANTA FE
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State | NM
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Zip | 87504-9880
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Country | US
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Telephone | 505-577-1862
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Fax | 505-466-9459
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | LPCC 0088061
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | MFC 2017
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License Number State | CA
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