Provider Demographics
NPI:1699922674
Name:BENNETT, DALE TODD (MED)
Entity type:Individual
Prefix:MR
First Name:DALE
Middle Name:TODD
Last Name:BENNETT
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 N BISBEE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLCOX
Mailing Address - State:AZ
Mailing Address - Zip Code:85643-1509
Mailing Address - Country:US
Mailing Address - Phone:520-909-8447
Mailing Address - Fax:
Practice Address - Street 1:480 N BISBEE AVE
Practice Address - Street 2:
Practice Address - City:WILLCOX
Practice Address - State:AZ
Practice Address - Zip Code:85643-1509
Practice Address - Country:US
Practice Address - Phone:520-384-8660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool