Basic Information
| Provider Information | |||||||||
| NPI: | 1558440206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTLEY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065436420 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | HARBORVIEW MEDICAL CENTER | ||||||||
| Address2: | 325 9TH AVE | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981042499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065986195 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | OP00001884 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 309470 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | P00054407 | 01 | WA | RAIL ROAD MEDICARE | OTHER | 0180284 | 01 | WA | L&I | OTHER | 1558440206 | 05 | WA | MEDICAID |