Healthcare Provider Details

I. General information

NPI: 1487869210
Provider Name (Legal Business Name): TRACY W BENNETT LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BELL ST
PORTLAND ME
04103-3418
US

IV. Provider business mailing address

1590 MILTON MILLS RD
ACTON ME
04001-5008
US

V. Phone/Fax

Practice location:
  • Phone: 207-604-2461
  • Fax: 207-514-8333
Mailing address:
  • Phone: 207-604-2461
  • Fax: 207-514-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC1576
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: