Provider Demographics
NPI:1912190364
Name:BENTLEY, THOMAS A (MSW)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 COASTAL HWY.
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327
Mailing Address - Country:US
Mailing Address - Phone:850-545-7953
Mailing Address - Fax:
Practice Address - Street 1:16 GOLD FINCH WAY
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-6209
Practice Address - Country:US
Practice Address - Phone:850-545-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL762219800Medicaid