Provider Demographics
NPI:1194723288
Name:BENDA, JOHN MICHAEL (LICSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:BENDA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 W 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4005 W 65TH ST
Practice Address - Street 2:SUITE #216
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1720
Practice Address - Country:US
Practice Address - Phone:612-929-0781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN132171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57G30BEOtherBLUE CROSS BLUE SHIELD
MN800001307Medicare PIN