Provider Demographics
NPI:1417629668
Name:BENNETT, TRACY ANN (APSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:BENNETT
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 S MOORLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4855 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:414-266-3339
Practice Address - Fax:414-425-9803
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131056-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417629668Medicaid