Healthcare Provider Details

I. General information

NPI: 1538955810
Provider Name (Legal Business Name): STACEY BENTLEY RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 N JEFF DAVIS DR
FAYETTEVILLE GA
30214-1875
US

IV. Provider business mailing address

304 DOTY DR # 304
THOMASTON GA
30286-3408
US

V. Phone/Fax

Practice location:
  • Phone: 877-498-0319
  • Fax:
Mailing address:
  • Phone: 470-473-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: