Provider Demographics
NPI:1821156258
Name:BENOWITZ, MINDY SUE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MINDY
Middle Name:SUE
Last Name:BENOWITZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 HUMBOLDT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1953
Mailing Address - Country:US
Mailing Address - Phone:612-870-0398
Mailing Address - Fax:612-822-2766
Practice Address - Street 1:2908 HUMBOLDT AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1953
Practice Address - Country:US
Practice Address - Phone:612-870-0398
Practice Address - Fax:612-822-2766
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1193103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN855350500Medicaid
MN3K446BEOtherBLUE CROSS BLUE SHIELD MN
MN3K446BEOtherBLUE CROSS BLUE SHIELD MN