Provider Demographics
NPI:1215955513
Name:BENNETT, JOHN (MA, LP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7066 STILLWATER BLVD N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3937
Mailing Address - Country:US
Mailing Address - Phone:651-777-5222
Mailing Address - Fax:651-251-5111
Practice Address - Street 1:8451 POINT DOUGLAS ROAD E
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016
Practice Address - Country:US
Practice Address - Phone:651-458-4116
Practice Address - Fax:651-458-5632
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2790103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN570033OtherP1
MN57129BEOtherBCBS
MN17574OtherHP
MN62-20082OtherUBH
MN106225OtherUC
MN252287OtherCP