Healthcare Provider Details

I. General information

NPI: 1659806693
Provider Name (Legal Business Name): THOMAS BENDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MAIN ST STE 108 DELTA, CO 81416
DELTA CO
81416-1834
US

IV. Provider business mailing address

540 MAIN ST STE 108 DELTA, CO 81416
DELTA CO
81416-1834
US

V. Phone/Fax

Practice location:
  • Phone: 505-681-1140
  • Fax: 970-874-2835
Mailing address:
  • Phone: 505-681-1140
  • Fax: 970-874-2835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0013088
License Number StateCO

VIII. Authorized Official

Name: THOMAS BENDER
Title or Position: OWNER
Credential:
Phone: 505-681-1140