=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992342240
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA W BENTLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2019
-----------------------------------------------------
Last Update Date | 12/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 148 MAIN ST
-----------------------------------------------------
City | BUCKSPORT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04416-4075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-479-4066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 83
-----------------------------------------------------
City | SULLIVAN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04664-0083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-479-4066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | XM5276
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------