Provider Demographics
NPI:1447351812
Name:BENSON, SHAWNA MARIE (PSY D, LP)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:MARIE
Last Name:BENSON
Suffix:
Gender:F
Credentials:PSY D, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11116 ZEALAND AVE N
Mailing Address - Street 2:# 117
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3594
Mailing Address - Country:US
Mailing Address - Phone:763-746-0842
Mailing Address - Fax:763-220-6025
Practice Address - Street 1:11116 ZEALAND AVE N
Practice Address - Street 2:SOUL WORK COUNSELING #117
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316
Practice Address - Country:US
Practice Address - Phone:763-746-0842
Practice Address - Fax:763-746-0843
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4564103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN933103400Medicaid
MN680001977Medicare ID - Type Unspecified