Provider Demographics
NPI:1043376635
Name:WALZ, BENEDICT A (MS MDV MAC LADC LMFT)
Entity Type:Individual
Prefix:
First Name:BENEDICT
Middle Name:A
Last Name:WALZ
Suffix:
Gender:M
Credentials:MS MDV MAC LADC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 W DIVISION ST
Mailing Address - Street 2:MIDTOWN SQUARE SUITE # 210
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4515
Mailing Address - Country:US
Mailing Address - Phone:320-252-5781
Mailing Address - Fax:320-252-5001
Practice Address - Street 1:3333 W DIVISION ST
Practice Address - Street 2:MIDTOWN SQUARE SUITE # 210
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4515
Practice Address - Country:US
Practice Address - Phone:320-252-5781
Practice Address - Fax:320-252-5001
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302151101YA0400X
101YM0800X, 101YP1600X, 101YP2500X
WI101YP1600X
MN#1763 LMFT101YP2500X
#302151101YA0400X
1763251S00000X
1763 & 302151251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional