Provider Demographics
NPI:1447972690
Name:KORTUEM, BENJAMIN (LP)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:KORTUEM
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7725 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-2501
Mailing Address - Country:US
Mailing Address - Phone:218-393-9309
Mailing Address - Fax:
Practice Address - Street 1:1409 WILLOW ST STE 600
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3288
Practice Address - Country:US
Practice Address - Phone:612-872-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6829103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical