Basic Information
| Provider Information | |||||||||
| NPI: | 1114511714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSTEDT | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | SSB-5 | ||||||||
| Address2: | 400 EAST THIRD STREET | ||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187868364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 615 PECAN AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558112749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183552100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2021 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 27270 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.