Healthcare Provider Details

I. General information

NPI: 1689853293
Provider Name (Legal Business Name): NELSON G. BENTLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SISTER PIERRE DR SUITE 107
TOWSON MD
21204-7516
US

IV. Provider business mailing address

120 SISTER PIERRE DR SUITE 107
TOWSON MD
21204-7516
US

V. Phone/Fax

Practice location:
  • Phone: 410-337-9441
  • Fax: 410-339-7169
Mailing address:
  • Phone: 410-337-9441
  • Fax: 410-339-7169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number01720
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0000759
License Number StateMD

VIII. Authorized Official

Name: NELSON G BENTLEY
Title or Position: OWNER
Credential: PHD
Phone: 410-337-9441