=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174892814
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT BENNETT PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2011
-----------------------------------------------------
Last Update Date | 12/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 TENNESSEE AVE NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20002-6425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-494-6675
-----------------------------------------------------
Fax | 708-801-7178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 TENNESSEE AVE NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20002-6425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-494-6675
-----------------------------------------------------
Fax | 170-880-1171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PSY1496
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------