Provider Demographics
NPI:1013920784
Name:BENTLEY, BENJAMIN K (LCAS, LCMHCS)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:K
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:LCAS, LCMHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5335 ROBINHOOD VILLAGE DR STE 155
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-9820
Mailing Address - Country:US
Mailing Address - Phone:336-905-9532
Mailing Address - Fax:
Practice Address - Street 1:6614 SHALLOWFORD RD STE 250
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9305
Practice Address - Country:US
Practice Address - Phone:336-945-0137
Practice Address - Fax:336-946-9084
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC685101YA0400X
NC4754101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102194Medicaid