Provider Demographics
NPI:1063942969
Name:BENIKE, TOM (LPC-IT)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:BENIKE
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-2252
Mailing Address - Country:US
Mailing Address - Phone:920-497-6161
Mailing Address - Fax:
Practice Address - Street 1:1499 6TH ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-2252
Practice Address - Country:US
Practice Address - Phone:920-497-6161
Practice Address - Fax:920-497-6161
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3512-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
3512-226OtherSTATE LICENSE