MEDICARE: DR. NICHOLAS KEITH BENNETT PSYD

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	103TC0700X	Clinical Psychologist	PSY33288	CA
2	103TC1900X	Counseling Psychologist	PSY33288	CA
3	103TC1900X	Counseling Psychologist		WV
4	103TC0700X	Clinical Psychologist	PSY.0006612	CO
5	103T00000X	Psychologist	1336	WV
6	103T00000X	Psychologist	PSY.0006612	CO
7	103TP2701X	Group Psychotherapy Psychologist	PSY33288	CA
8	103TF0200X	Forensic Psychologist	PSY33288	CA
9	103T00000X	Psychologist	PSY33288	CA

General Provider Information

NPI Number	:	1508325903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS KEITH BENNETT PSYD

Provider Business Mailing Address
First Line	:	1301 N BROADWAY STE 32424
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90012-1408
Country	:	US
Telephone Number	:	805-225-4446
Fax Number	:	805-273-0206

Provider Business Practice Location Address
First Line	:	1301 N BROADWAY STE 32424
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90012-1408
Country	:	US
Telephone Number	:	805-225-4446
Fax Number	:	805-273-0206

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

Provider Enumeration Date	:	03/15/2019
Last Update Date	:	12/09/2025

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