Provider Demographics
NPI:1871912287
Name:BENNETT, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2710
Mailing Address - Country:US
Mailing Address - Phone:619-575-4687
Mailing Address - Fax:618-575-1215
Practice Address - Street 1:829 27TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2710
Practice Address - Country:US
Practice Address - Phone:619-575-4687
Practice Address - Fax:618-575-1215
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA92710101YM0800X
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program