Provider Demographics
NPI:1417255753
Name:BENGTSON, BRADLEY S
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:S
Last Name:BENGTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 VILLAGE PKWY
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-4409
Mailing Address - Country:US
Mailing Address - Phone:612-644-2502
Mailing Address - Fax:
Practice Address - Street 1:33 VILLAGE PKWY
Practice Address - Street 2:SUITE 109
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-4409
Practice Address - Country:US
Practice Address - Phone:612-644-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4712103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling