Provider Demographics
NPI:1205379500
Name:BLECK-OWENS, BENJAMIN MICHAEL (LPCIT SACIT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:MICHAEL
Last Name:BLECK-OWENS
Suffix:
Gender:M
Credentials:LPCIT SACIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 W. VLIET STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208
Mailing Address - Country:US
Mailing Address - Phone:414-476-1073
Mailing Address - Fax:414-476-0223
Practice Address - Street 1:5508 W. VLIET STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:414-476-1073
Practice Address - Fax:414-476-0223
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WI17353-130101YA0400X
WI2718-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health