Provider Demographics
NPI:1487032926
Name:BENGTSON, CHARLINE
Entity Type:Individual
Prefix:
First Name:CHARLINE
Middle Name:
Last Name:BENGTSON
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 1:105 2ND AVE NE STE 110
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1226
Mailing Address - Country:US
Mailing Address - Phone:320-428-0744
Mailing Address - Fax:320-438-2928
Practice Address - Street 1:105 2ND AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1226
Practice Address - Country:US
Practice Address - Phone:320-428-0744
Practice Address - Fax:320-438-2829
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11524106H00000X
MN3047106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1487032926Medicaid