Provider Demographics
NPI:1508374778
Name:BENTLEY, BRIAN L
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 WILD ROSE LANE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266
Mailing Address - Country:US
Mailing Address - Phone:515-822-5686
Mailing Address - Fax:515-661-6101
Practice Address - Street 1:5500 WILD ROSE LANE
Practice Address - Street 2:SUITE 400
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266
Practice Address - Country:US
Practice Address - Phone:515-822-5686
Practice Address - Fax:515-661-6101
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA09002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA09002OtherCADC