Healthcare Provider Details

I. General information

NPI: 1619894060
Provider Name (Legal Business Name): TRACY EILEEN BENNETT MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23670 HAWTHORNE BLVD STE 205
TORRANCE CA
90505-5978
US

IV. Provider business mailing address

1632 W 125TH ST
LOS ANGELES CA
90047-5222
US

V. Phone/Fax

Practice location:
  • Phone: 626-768-0887
  • Fax:
Mailing address:
  • Phone: 323-717-7391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number125399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: