Healthcare Provider Details

I. General information

NPI: 1154006393
Provider Name (Legal Business Name): KALLI KIM BENTZ LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 E CAMELBACK RD
PHOENIX AZ
85016-4311
US

IV. Provider business mailing address

2850 E CAMELBACK RD
PHOENIX AZ
85016-4311
US

V. Phone/Fax

Practice location:
  • Phone: 602-975-8959
  • Fax:
Mailing address:
  • Phone: 602-975-8959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLAC-23227
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: