Provider Demographics
NPI:1457311789
Name:BENJAMIN, MICHAEL CHARLES (LICSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5255 MEMBERS PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-8381
Mailing Address - Country:US
Mailing Address - Phone:507-218-3701
Mailing Address - Fax:
Practice Address - Street 1:5255 MEMBERS PKWY NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-8381
Practice Address - Country:US
Practice Address - Phone:507-218-3701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW262971041C0700X
MN206591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN800002686Medicare PIN