Provider Demographics
NPI:1417063132
Name:BENNETT, MARY LOUISE (MFT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 E ATHERTON ST
Mailing Address - Street 2:SUITE 416
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-4016
Mailing Address - Country:US
Mailing Address - Phone:562-493-1496
Mailing Address - Fax:562-493-2092
Practice Address - Street 1:5500 E ATHERTON ST
Practice Address - Street 2:SUITE 416
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-4016
Practice Address - Country:US
Practice Address - Phone:562-493-1496
Practice Address - Fax:562-493-2092
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT31239106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist