Provider Demographics
NPI:1730332255
Name:BENDER, MARK GERALD (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:GERALD
Last Name:BENDER
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 1:204 MENDELSSOHN CT
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-5378
Mailing Address - Country:US
Mailing Address - Phone:707-794-9337
Mailing Address - Fax:
Practice Address - Street 1:204 MENDELSSOHN CT
Practice Address - Street 2:
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931-5378
Practice Address - Country:US
Practice Address - Phone:707-794-9337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9697103TC0700X
CAPSY 9697103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty