Provider Demographics
NPI:1891424735
Name:BRANDVOLD, BENNETT (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:
Last Name:BRANDVOLD
Suffix:
Gender:M
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 HIGHWAY 169 N STE 220
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-4058
Mailing Address - Country:US
Mailing Address - Phone:612-517-1577
Mailing Address - Fax:
Practice Address - Street 1:4900 HIGHWAY 169 N STE 220
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-4058
Practice Address - Country:US
Practice Address - Phone:612-517-1577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28626104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker