Provider Demographics
NPI:1457068371
Name:BENSON, AMANDA (LAC, MCM)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BENSON
Suffix:
Gender:F
Credentials:LAC, MCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 PINEVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-5768
Mailing Address - Country:US
Mailing Address - Phone:763-222-8337
Mailing Address - Fax:
Practice Address - Street 1:11500 HIGHWAY 7 STE 204
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5107
Practice Address - Country:US
Practice Address - Phone:763-222-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2016171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2016OtherMINNESOTA STATE LICENSE NUMBER