=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689666349
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANDREA L BENJAMIN MALP LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 137 W 1ST ST
-----------------------------------------------------
City | WACONIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55387-1190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-442-5005
-----------------------------------------------------
Fax | 952-442-7586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 W 1ST ST
-----------------------------------------------------
City | WACONIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55387-1190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-442-5005
-----------------------------------------------------
Fax | 952-442-7586
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCOLOGIST
-----------------------------------------------------
Name | ANDREA L BENJAMIN
-----------------------------------------------------
Credential | MALP
-----------------------------------------------------
Telephone | 952-442-5005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | LP2926
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------