Provider Demographics
NPI:1538178827
Name:BRAD BENNETT PSYCHOLOGY PC
Entity type:Organization
Organization Name:BRAD BENNETT PSYCHOLOGY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:315-859-1973
Mailing Address - Street 1:7325 STATE ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-3435
Mailing Address - Country:US
Mailing Address - Phone:315-859-1973
Mailing Address - Fax:315-859-1979
Practice Address - Street 1:7325 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-3435
Practice Address - Country:US
Practice Address - Phone:315-859-1973
Practice Address - Fax:315-859-1979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8120-0103TC0700X
NY1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0183Medicare ID - Type Unspecified