Provider Demographics
NPI:1548095839
Name:BENTON, TRACI L (COUNSELING INTERN)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:BENTON
Suffix:
Gender:F
Credentials:COUNSELING INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9028 W SAN JUAN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2288
Mailing Address - Country:US
Mailing Address - Phone:623-203-3970
Mailing Address - Fax:
Practice Address - Street 1:9028 W SAN JUAN AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-2288
Practice Address - Country:US
Practice Address - Phone:623-203-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor