Provider Demographics
NPI:1023030442
Name:BENSON, BRADFORD B (LISCW)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:B
Last Name:BENSON
Suffix:
Gender:M
Credentials:LISCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3332 DELTA AVE
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-4502
Mailing Address - Country:US
Mailing Address - Phone:952-945-0057
Mailing Address - Fax:
Practice Address - Street 1:3332 DELTA AVE
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-4502
Practice Address - Country:US
Practice Address - Phone:952-945-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical