Provider Demographics
NPI:1437540929
Name:BENSON PSYCHOLOGICAL SERVICES, PC
Entity type:Organization
Organization Name:BENSON PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-297-7540
Mailing Address - Street 1:1308 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3707
Mailing Address - Country:US
Mailing Address - Phone:701-297-7540
Mailing Address - Fax:701-297-6439
Practice Address - Street 1:200 5TH ST S
Practice Address - Street 2:SUITE 205
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:701-297-7540
Practice Address - Fax:701-297-6439
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENSON PSYCHOLOGICAL SERVICES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00827101YP2500X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10250Medicaid
NDN714182Medicare UPIN