Provider Demographics
NPI:1881222677
Name:BENTER, BRADLEY JUSTIN (AMFT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JUSTIN
Last Name:BENTER
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:BENTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10116 JIBBOOM ST
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-0101
Mailing Address - Country:US
Mailing Address - Phone:209-417-2819
Mailing Address - Fax:
Practice Address - Street 1:10116 JIBBOOM ST
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0101
Practice Address - Country:US
Practice Address - Phone:209-417-2819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110993103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist