Provider Demographics
NPI:1689666349
Name:ANDREA L BENJAMIN MALP LTD
Entity type:Organization
Organization Name:ANDREA L BENJAMIN MALP LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MALP
Authorized Official - Phone:952-442-5005
Mailing Address - Street 1:137 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1190
Mailing Address - Country:US
Mailing Address - Phone:952-442-5005
Mailing Address - Fax:952-442-7586
Practice Address - Street 1:137 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1190
Practice Address - Country:US
Practice Address - Phone:952-442-5005
Practice Address - Fax:952-442-7586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2926103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7H308BEOtherBCBS