Healthcare Provider Details

I. General information

NPI: 1336277284
Provider Name (Legal Business Name): MR. GARY VAN BENTLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 OLD FLORENCE RD
LAWRENCEBURG TN
38464-8401
US

IV. Provider business mailing address

1090 OLD FLORENCE RD
LAWRENCEBURG TN
38464-8401
US

V. Phone/Fax

Practice location:
  • Phone: 931-762-6505
  • Fax: 931-762-3690
Mailing address:
  • Phone: 931-762-6505
  • Fax: 931-762-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: