Provider Demographics
NPI:1710124227
Name:BENTZ, LISA (LCAS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BENTZ
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609A PINER RD STE 182
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-4201
Mailing Address - Country:US
Mailing Address - Phone:910-619-7500
Mailing Address - Fax:
Practice Address - Street 1:201 N FRONT ST STE 713
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-5090
Practice Address - Country:US
Practice Address - Phone:910-619-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1358101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112068Medicaid