Provider Demographics
NPI:1053852954
Name:BENNETT, SHANNON (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 W GAINES ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32306-1603
Mailing Address - Country:US
Mailing Address - Phone:850-644-9926
Mailing Address - Fax:850-644-6591
Practice Address - Street 1:715 W GAINES ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32306-1603
Practice Address - Country:US
Practice Address - Phone:850-644-9926
Practice Address - Fax:850-644-6591
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 9086103T00000X
FLSS 1235103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool