Provider Demographics
NPI:1992540876
Name:BENJAMIN DE BOER PSYD LLC
Entity type:Organization
Organization Name:BENJAMIN DE BOER PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:I
Authorized Official - Last Name:DE BOER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:608-886-9697
Mailing Address - Street 1:2800 E ENTERPRISE AVE STE 333
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2824 FRISEE DR
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-8502
Practice Address - Country:US
Practice Address - Phone:608-886-9697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical