Provider Demographics
NPI:1487869210
Name:BENNETT, TRACY W (LCPC)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:W
Last Name:BENNETT
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 MILTON MILLS RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:ME
Mailing Address - Zip Code:04001-5008
Mailing Address - Country:US
Mailing Address - Phone:207-604-2461
Mailing Address - Fax:207-514-8333
Practice Address - Street 1:55 BELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3418
Practice Address - Country:US
Practice Address - Phone:207-604-2461
Practice Address - Fax:207-514-8333
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC1576101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health