Provider Demographics
NPI:1275799611
Name:BENTLEY, BILLIE JEAN (COTA)
Entity Type:Individual
Prefix:
First Name:BILLIE
Middle Name:JEAN
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-2300
Mailing Address - Country:US
Mailing Address - Phone:906-863-1599
Mailing Address - Fax:
Practice Address - Street 1:501 N LAKE ST
Practice Address - Street 2:
Practice Address - City:PESHTIGO
Practice Address - State:WI
Practice Address - Zip Code:54157-1013
Practice Address - Country:US
Practice Address - Phone:715-582-3906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1737-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41072000Medicaid