Healthcare Provider Details

I. General information

NPI: 1629802905
Provider Name (Legal Business Name): TANESHA BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

IV. Provider business mailing address

5331 S MACADAM AVE STE 287
PORTLAND OR
97239-3849
US

V. Phone/Fax

Practice location:
  • Phone: 626-590-4933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: