Healthcare Provider Details

I. General information

NPI: 1457311789
Provider Name (Legal Business Name): MICHAEL CHARLES BENJAMIN LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 MEMBERS PKWY NW
ROCHESTER MN
55901-8381
US

IV. Provider business mailing address

5255 MEMBERS PKWY NW
ROCHESTER MN
55901-8381
US

V. Phone/Fax

Practice location:
  • Phone: 507-218-3701
  • Fax:
Mailing address:
  • Phone: 507-218-3701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW26297
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20659
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: