Provider Demographics
NPI:1720323801
Name:BENTLEY, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-1817
Mailing Address - Country:US
Mailing Address - Phone:806-799-8950
Mailing Address - Fax:806-799-8939
Practice Address - Street 1:1600 S COULTER ST
Practice Address - Street 2:A105
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1710
Practice Address - Country:US
Practice Address - Phone:806-352-2321
Practice Address - Fax:806-355-8941
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11112237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist