Healthcare Provider Details

I. General information

NPI: 1801311576
Provider Name (Legal Business Name): TRACEY DIANE VAN ETTEN MS, AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21030 MISSION ST STE B
TEHACHAPI CA
93561-6769
US

IV. Provider business mailing address

6077 COFFEE ROAD STE 4 PMB 145
BAKERSFIELD CA
93308-2135
US

V. Phone/Fax

Practice location:
  • Phone: 661-748-4767
  • Fax:
Mailing address:
  • Phone: 661-748-4767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number109289
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: