Provider Demographics
NPI:1245585819
Name:BENTLEY, DIANNE (TEACHING, PSYCH ASST)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:TEACHING, PSYCH ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W PLEASANT ST APT 219
Mailing Address - Street 2:
Mailing Address - City:COALINGA
Mailing Address - State:CA
Mailing Address - Zip Code:93210-2372
Mailing Address - Country:US
Mailing Address - Phone:626-710-6975
Mailing Address - Fax:
Practice Address - Street 1:100 PRISON RD
Practice Address - Street 2:
Practice Address - City:REPRESA
Practice Address - State:CA
Practice Address - Zip Code:95671-2372
Practice Address - Country:US
Practice Address - Phone:916-985-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2023-06-07
Deactivation Date:2023-05-03
Deactivation Code:
Reactivation Date:2023-05-23
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA954505783103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program