Individual
MS. PENNY MAIN-BENNETT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LADC
Contact information
Practice address
16525 HIGHWAY 65 NE, HAM LAKE X, MN 55304-5300
(763) 413-8838
(763) 413-8878
Mailing address
4003 SUNSHINE DR, ANOKA, MN 55303-8606
(763) 413-8838
(763) 413-8878
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
1010135-1-CDT
MN
101YA0400X
Addiction (Substance Use Disorder) Counselor
300832
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1030158
PREFERRED ONE
MN
01
—
5040353
UBH
MN
01
—
6C74GR
BCBS OF MN
MN
Enumeration date
02/26/2007
Last updated
07/08/2007
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