Provider Demographics
NPI:1992342240
Name:BENTLEY, TINA W
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:W
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:ME
Mailing Address - Zip Code:04664-0083
Mailing Address - Country:US
Mailing Address - Phone:207-479-4066
Mailing Address - Fax:
Practice Address - Street 1:148 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416-4075
Practice Address - Country:US
Practice Address - Phone:207-479-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXM5276106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist