Provider Demographics
NPI:1124565833
Name:BENTLEY, GERALD (LPC)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7454 GRANT VILLAGE DR
Mailing Address - Street 2:APT. A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-1434
Mailing Address - Country:US
Mailing Address - Phone:314-458-5798
Mailing Address - Fax:
Practice Address - Street 1:5910 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-3407
Practice Address - Country:US
Practice Address - Phone:314-352-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013002018101YP2500X
MO0441047101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional