Provider Demographics
NPI:1497260434
Name:BENSON, GINA (BS, LADC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:BS, LADC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:MAKARRALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:524 25TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-3255
Mailing Address - Country:US
Mailing Address - Phone:320-202-1909
Mailing Address - Fax:320-202-1910
Practice Address - Street 1:524 25TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-3255
Practice Address - Country:US
Practice Address - Phone:320-202-1909
Practice Address - Fax:320-202-1910
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-20
Deactivation Date:2017-12-14
Deactivation Code:
Reactivation Date:2017-12-20
Provider Licenses
StateLicense IDTaxonomies
MN304763101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)