Provider Demographics
NPI:1720595895
Name:BARTLEY, BIANCA (MA, TLLP)
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:
Last Name:BARTLEY
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18670 VAN HORN RD APT 5
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22601 ALLEN RD STE 300
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-2273
Practice Address - Country:US
Practice Address - Phone:517-936-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007910103T00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103T00000XBehavioral Health & Social Service ProvidersPsychologist