Provider Demographics
NPI:1861590705
Name:TITTLER, BENNETT I (PHD)
Entity type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:I
Last Name:TITTLER
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 1:47 CROSMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-1412
Mailing Address - Country:US
Mailing Address - Phone:781-581-9547
Mailing Address - Fax:
Practice Address - Street 1:30 BOSTON ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904-2540
Practice Address - Country:US
Practice Address - Phone:781-599-3109
Practice Address - Fax:781-599-3162
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3194103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW03410Medicare ID - Type Unspecified