Provider Demographics
NPI:1598837783
Name:BENTZ, THOMAS D (LCSW, PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:BENTZ
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54768-1011
Mailing Address - Country:US
Mailing Address - Phone:715-644-4357
Mailing Address - Fax:715-644-5053
Practice Address - Street 1:224 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768-1011
Practice Address - Country:US
Practice Address - Phone:715-644-4357
Practice Address - Fax:715-644-5053
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1604-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI395-13300Medicaid
WI78034OtherSECURITY HEALTH PLAN