Provider Demographics
NPI:1841990280
Name:FOX, BENJAMIN STANSFIELD
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:STANSFIELD
Last Name:FOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:PAULLINA
Mailing Address - State:IA
Mailing Address - Zip Code:51046-0051
Mailing Address - Country:US
Mailing Address - Phone:763-528-3110
Mailing Address - Fax:
Practice Address - Street 1:122 S RUTLEDGE ST
Practice Address - Street 2:
Practice Address - City:PAULLINA
Practice Address - State:IA
Practice Address - Zip Code:51046-7822
Practice Address - Country:US
Practice Address - Phone:763-528-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IARBT23-262139106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician