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NPI Code Detail

MEDICARE: MARY BENSON

MEDICARE: MARY BENSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2103T00000XPsychologistLP6216MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11174985030OTHERMNNPI I

General Provider Information

NPI Number : 1174985030
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY BENSON
Provider Business Mailing Address
First Line : 723 6TH ST SW
Second Line :
City : ROCHESTER
State : MN
Zip : 55902-2971
Country : US
Telephone Number : 320-260-0873
Fax Number :
Provider Business Practice Location Address
First Line : 3737 40TH AVE NW
Second Line :
City : ROCHESTER
State : MN
Zip : 55901-1772
Country : US
Telephone Number : 507-288-6978
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/22/2016
Last Update Date : 10/22/2020

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