Provider Demographics
NPI:1942757992
Name:BENTLEY, DEIDRA R (LPC)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:R
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3755 REDWINE RD APT 11210
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30344
Mailing Address - Country:US
Mailing Address - Phone:404-729-0760
Mailing Address - Fax:
Practice Address - Street 1:3755 REDWINE RD APT 11210
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30344-5975
Practice Address - Country:US
Practice Address - Phone:404-729-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008407101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health