=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972649689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENNETT STEVEN SLOTNICK PH D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 12/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 STORER ST
-----------------------------------------------------
City | KENNEBUNK
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04043-6875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-467-8215
-----------------------------------------------------
Fax | 207-604-5024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 OCEAN AVE PO BOX 310
-----------------------------------------------------
City | OLD ORCHARD BEACH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04064-2407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-934-5858
-----------------------------------------------------
Fax | 207-934-6111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 1718
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 310
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PS921
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS921
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1718
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 310
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PS921
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 1718
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 310
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------