Provider Demographics
NPI:1821690546
Name:BENZ, KAITLYN ELIZABETH (LSW, LADC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:BENZ
Suffix:
Gender:F
Credentials:LSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 MARLOWE AVE NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-7435
Mailing Address - Country:US
Mailing Address - Phone:612-816-5019
Mailing Address - Fax:
Practice Address - Street 1:210 GATEWAY DR NE STE 4
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1621
Practice Address - Country:US
Practice Address - Phone:218-230-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28796104100000X
MN305848101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker