Provider Demographics
NPI:1285790360
Name:BENNETT, TRACY S (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:S
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 1:340 ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-5927
Mailing Address - Country:US
Mailing Address - Phone:805-383-0882
Mailing Address - Fax:805-383-0882
Practice Address - Street 1:340 ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-5927
Practice Address - Country:US
Practice Address - Phone:805-383-0882
Practice Address - Fax:805-383-0882
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15696103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical