MEDICARE: MS. MARY LOUISE BENNETT MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFT31239	CA

General Provider Information

NPI Number	:	1417063132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY LOUISE BENNETT MFT

Provider Business Mailing Address
First Line	:	5500 E ATHERTON ST
Second Line	:	SUITE 416
City	:	LONG BEACH
State	:	CA
Zip	:	90815-4016
Country	:	US
Telephone Number	:	562-493-1496
Fax Number	:	562-493-2092

Provider Business Practice Location Address
First Line	:	5500 E ATHERTON ST
Second Line	:	SUITE 416
City	:	LONG BEACH
State	:	CA
Zip	:	90815-4016
Country	:	US
Telephone Number	:	562-493-1496
Fax Number	:	562-493-2092

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	07/08/2007

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