MEDICARE: DR. PHYLLIS BENTLEY BALES PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LH00003585	WA

General Provider Information

NPI Number	:	1629151634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHYLLIS BENTLEY BALES PH.D.

Provider Business Mailing Address
First Line	:	718 42ND AVE NW
Second Line	:
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-7707
Country	:	US
Telephone Number	:	253-851-5502
Fax Number	:	253-851-8108

Provider Business Practice Location Address
First Line	:	718 42ND AVE NW
Second Line	:
City	:	GIG HARBOR
State	:	WA
Zip	:	98335-7707
Country	:	US
Telephone Number	:	253-851-5502
Fax Number	:	253-851-8108

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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