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General NPI Number Information
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NPI Number | 1104528199
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Entity Type | Individual
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Provider Name | OCTAVIA BENTUM
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Gender | Female
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Dates
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Enumeration Date | 03/21/2023
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Last Update Date | 10/17/2023
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Provider Practice Location Address
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Address Line | 12225 GREENVILLE AVE # 600
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City | DALLAS
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State | TX
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Zip | 75243-9362
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Country | US
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Telephone | 888-265-1068
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Fax |
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Provider Business Mailing Address
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Address Line | 12225 GREENVILLE AVE # 600
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City | DALLAS
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State | TX
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Zip | 75243-9362
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number | 7772
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number | 43535
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License Number State | TX
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