Provider Demographics
NPI:1912162124
Name:BENTLEY, MIRANDA S (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:S
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 EQUESTRIAN DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-0632
Mailing Address - Country:US
Mailing Address - Phone:765-490-8096
Mailing Address - Fax:
Practice Address - Street 1:300 WINDY HILL DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-2862
Practice Address - Country:US
Practice Address - Phone:765-477-7791
Practice Address - Fax:765-474-2986
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004533A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist