Provider Demographics
NPI:1134840697
Name:BENNETT, KENNETH PETER (PHD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PETER
Last Name:BENNETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3687 VETERANS DR # 169-183
Mailing Address - Street 2:
Mailing Address - City:FORT HARRISON
Mailing Address - State:MT
Mailing Address - Zip Code:59636-9700
Mailing Address - Country:US
Mailing Address - Phone:406-447-6027
Mailing Address - Fax:
Practice Address - Street 1:3687 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636-9700
Practice Address - Country:US
Practice Address - Phone:406-447-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203704103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical