Provider Demographics
NPI:1063528123
Name:BENDEWALD, GAYLEN (MSW)
Entity type:Individual
Prefix:MR
First Name:GAYLEN
Middle Name:
Last Name:BENDEWALD
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 S TENNIS LN
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-2256
Mailing Address - Country:US
Mailing Address - Phone:605-334-6211
Mailing Address - Fax:605-362-5601
Practice Address - Street 1:4410 S TENNIS LN
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-2256
Practice Address - Country:US
Practice Address - Phone:605-334-6211
Practice Address - Fax:605-362-5601
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLCSW-PIP 4441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6570034Medicaid
SD6570034Medicaid