Healthcare Provider Details

I. General information

NPI: 1326653601
Provider Name (Legal Business Name): SHIRLEY R BENSON-ROGERS MS, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2020
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 BLAISDELL AVE
MINNEAPOLIS MN
55404-2415
US

IV. Provider business mailing address

2118 BLAISDELL AVE
MINNEAPOLIS MN
55404-2415
US

V. Phone/Fax

Practice location:
  • Phone: 612-235-6259
  • Fax: 612-872-8855
Mailing address:
  • Phone: 612-235-6259
  • Fax: 612-872-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC03443
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number305600
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: