Provider Demographics
NPI:1225601214
Name:BENGTSON, LILLIAN (SE)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:SE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:
Practice Address - Street 1:500 S 11TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4880
Practice Address - Country:US
Practice Address - Phone:208-232-7862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IDSE203528390200000X
ID9871578103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program