Provider Demographics
NPI:1295718484
Name:BENGTSON, BRENT (NMN) (LSCSW, LCSW, ACSW)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:(NMN)
Last Name:BENGTSON
Suffix:
Gender:M
Credentials:LSCSW, LCSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12815 W 118TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-1311
Mailing Address - Country:US
Mailing Address - Phone:913-339-9395
Mailing Address - Fax:
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:MUNSON ARMY HEALTH CENTER ATTN: MCXN-COD MS. CUTTON
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6562
Practice Address - Fax:913-684-6208
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW #5501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical