Provider Demographics
NPI:1801311576
Name:VAN ETTEN, TRACEY DIANE (MS, AMFT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:DIANE
Last Name:VAN ETTEN
Suffix:
Gender:F
Credentials:MS, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6077 COFFEE ROAD STE 4
Mailing Address - Street 2:PMB 145
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-2135
Mailing Address - Country:US
Mailing Address - Phone:661-748-4767
Mailing Address - Fax:
Practice Address - Street 1:21030 MISSION ST STE B
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-6769
Practice Address - Country:US
Practice Address - Phone:661-748-4767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA109289106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty