MEDICARE: SUSAN LESLIE BENNETT PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TH0004X	Health Psychologist	3664	CO
2	103TC1900X	Counseling Psychologist	3664	CO

General Provider Information

NPI Number	:	1083991236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN LESLIE BENNETT PH.D.

Provider Business Mailing Address
First Line	:	4700 HALE PKWY STE 380
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80220-4023
Country	:	US
Telephone Number	:	720-515-2140
Fax Number	:	720-408-2541

Provider Business Practice Location Address
First Line	:	4700 HALE PKWY STE 380
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80220-4023
Country	:	US
Telephone Number	:	720-515-2140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2011
Last Update Date	:	07/21/2022

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