Provider Demographics
NPI:1952456402
Name:BENTLEY, JANICE (PSYD LMSW)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:PSYD LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1767
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1767
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:2828 KRAFT AVE SE
Practice Address - Street 2:SUITE 186
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-7700
Practice Address - Country:US
Practice Address - Phone:616-949-9550
Practice Address - Fax:616-949-9551
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801063539104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8008943530OtherBCBSM PROVIDER
MI8008943530OtherBCBSM PROVIDER