Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YP2500X | Professional Counselor | 2013002018 | MO |
Y | 101YS0200X | School Counselor | 0441047 | MO |
NPI | 1124565833 |
---|---|
Provider Name | Gerald Bentley |
First Address | Saint Louis, MO 63123-1434 |
Second Address | Saint Louis, MO 63109-3407 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2017 |
Last Update Date | 20/01/2017 |