Provider Demographics
NPI:1073840732
Name:BENTLEY, MADISON (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 CONNOR CIR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-6137
Mailing Address - Country:US
Mailing Address - Phone:706-836-2224
Mailing Address - Fax:
Practice Address - Street 1:801 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3711
Practice Address - Country:US
Practice Address - Phone:706-836-2224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005710101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional