Provider Demographics
NPI:1710589866
Name:BENTSEN, STACY JEANETTE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JEANETTE
Last Name:BENTSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-9400
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:
Practice Address - Street 1:109 LEROUX ST
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-1038
Practice Address - Country:US
Practice Address - Phone:573-663-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1710589866101YP2500X
390200000X
MO2021051208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program