Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | LP2096 | MN |
Y | 103TC0700X | Clinical Psychologist | LP2096 | MN |
NPI | 1003029265 |
---|---|
Provider Name | Cathleen Bengtson |
First Address | Grand Rapids, MN 55744-3615 |
Second Address | Grand Rapids, MN 55744-3615 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1009423 | PREFERRED ONE (01) | MN |
57460BE | BCBS OF MINNESOTA (01) | MN |
62 20161 | UBH (01) | MN |