Healthcare Provider Details

I. General information

NPI: 1992104715
Provider Name (Legal Business Name): BREANNE BENEDICT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 01/03/2022
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 W GRANT LINE RD
TRACY CA
95377-7309
US

IV. Provider business mailing address

2185 W GRANT LINE RD
TRACY CA
95377-7309
US

V. Phone/Fax

Practice location:
  • Phone: 209-839-6299
  • Fax:
Mailing address:
  • Phone: 209-839-6233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number30435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: