Provider Demographics
NPI:1316149792
Name:BENNETT, MATTHEW SCOTT (PHD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:BENNETT
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 1:1701 BURNT BOAT DR FL 2
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0812
Mailing Address - Country:US
Mailing Address - Phone:701-323-0924
Mailing Address - Fax:701-323-0935
Practice Address - Street 1:1701 BURNT BOAT DR FL 2
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0812
Practice Address - Country:US
Practice Address - Phone:701-323-0924
Practice Address - Fax:701-323-0935
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND394103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDBEN28274OtherBCBS OF ND
ND14194Medicaid
ND14194Medicaid