Provider Demographics
NPI:1124134226
Name:RAPP-BENNETT, LINDA R (PHD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:R
Last Name:RAPP-BENNETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:RUTH
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:490 CROSS KEYS OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450
Mailing Address - Country:US
Mailing Address - Phone:585-223-0810
Mailing Address - Fax:585-425-1552
Practice Address - Street 1:490 CROSS KEYS OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450
Practice Address - Country:US
Practice Address - Phone:585-223-0810
Practice Address - Fax:585-425-1552
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007397103T00000X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7193383OtherAETNA
7700150OtherMVP HEALTH CARE
NYP010007397OtherBC/BS- EXSELLUS
NY100241FCOtherPREFERRED CARE