Provider Demographics
NPI:1265901169
Name:BENTLEY, MORIAH
Entity type:Individual
Prefix:
First Name:MORIAH
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 92ND ST S APT 2
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-9268
Mailing Address - Country:US
Mailing Address - Phone:253-221-6636
Mailing Address - Fax:
Practice Address - Street 1:1100 NE 45TH ST STE 600
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4696
Practice Address - Country:US
Practice Address - Phone:206-607-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMG61009098106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program