Basic Information
| Provider Information | |||||||||
| NPI: | 1578758223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENNETT | ||||||||
| OtherFirstName: | SUSIE | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19 LINCOLN ST APT 1N | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060823391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263761654 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 77 MILL ST | ||||||||
| Address2: | STE 251 | ||||||||
| City: | WESTFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010855402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135686141 | ||||||||
| FaxNumber: | 4135724117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.