Provider Demographics
NPI:1093138331
Name:BADER, BENJAMIN (LMFT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BADER
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12915 63RD AVE. N.
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:952-826-8412
Mailing Address - Fax:763-383-5802
Practice Address - Street 1:12915 63RD AVE. N.
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:952-826-8412
Practice Address - Fax:763-383-5802
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2711106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist