Provider Demographics
NPI:1396981007
Name:BENTSON, SCOTT BRADLEY (LP)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:BRADLEY
Last Name:BENTSON
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 LABREE AVE S
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2840
Mailing Address - Country:US
Mailing Address - Phone:218-681-4240
Mailing Address - Fax:218-683-4632
Practice Address - Street 1:120 LABREE AVE S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2840
Practice Address - Country:US
Practice Address - Phone:218-681-4240
Practice Address - Fax:218-683-4632
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4989103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN897047500Medicaid
MN897047500Medicaid