1912309006 NPI number — MISS COURTNEY BENTLEY LSW, CAA

Table of content: MISS COURTNEY BENTLEY LSW, CAA (NPI 1912309006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912309006 NPI number — MISS COURTNEY BENTLEY LSW, CAA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENTLEY
Provider First Name:
COURTNEY
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LSW, CAA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912309006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5400 EDALBERT DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45239-7695
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-741-3100
Provider Business Mailing Address Fax Number:
513-741-5686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3131 S DIXIE DR
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
MORAINE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45439-2256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-643-0398
Provider Business Practice Location Address Fax Number:
937-643-0398
Provider Enumeration Date:
09/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  S1303480 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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