Provider Demographics
NPI:1184648081
Name:HOUSE, BENJAMIN THOMAS JR (LISW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:HOUSE
Suffix:JR
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 RAVINA DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50313-3211
Mailing Address - Country:US
Mailing Address - Phone:515-288-4120
Mailing Address - Fax:515-244-0714
Practice Address - Street 1:1119 RAVINA DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50313-3211
Practice Address - Country:US
Practice Address - Phone:515-288-4120
Practice Address - Fax:515-244-0714
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0113290Medicaid
IA0113290Medicaid