Provider Demographics
NPI:1427526797
Name:BENTLEY, CARRISSA (LSWAIC)
Entity type:Individual
Prefix:
First Name:CARRISSA
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 185TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-2369
Mailing Address - Country:US
Mailing Address - Phone:208-310-0266
Mailing Address - Fax:
Practice Address - Street 1:3901 S. FIFE STREET
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409
Practice Address - Country:US
Practice Address - Phone:253-589-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60902419104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker