Provider Demographics
NPI:1174985030
Name:BENSON, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 6TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-2971
Mailing Address - Country:US
Mailing Address - Phone:320-260-0873
Mailing Address - Fax:
Practice Address - Street 1:3737 40TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1772
Practice Address - Country:US
Practice Address - Phone:507-288-6978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MNLP6216103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1174985030OtherNPI I