=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891054805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLA ANNE BENTLEY MS, LADAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2012
-----------------------------------------------------
Last Update Date | 05/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 S KING AVE
-----------------------------------------------------
City | DYERSBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38024-4614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-287-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 BEAVER CREEK CV
-----------------------------------------------------
City | DYERSBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38024-7412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-445-0112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 999
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------