Provider Demographics
NPI:1629314216
Name:BENTLEY, LISA RENAYE (LPC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENAYE
Last Name:BENTLEY
Suffix:
Gender:F
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:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:BARIUM SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:28010-0001
Mailing Address - Country:US
Mailing Address - Phone:707-873-1011
Mailing Address - Fax:704-832-2253
Practice Address - Street 1:209 BARIUM SPRINGS DRIVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-6238
Practice Address - Country:US
Practice Address - Phone:707-873-1011
Practice Address - Fax:704-832-2253
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4233101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4233OtherLPC