Provider Demographics
NPI:1477727097
Name:CHENEY, BENJAMIN R (MSW, LCSW-SAS, CCTP)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:R
Last Name:CHENEY
Suffix:
Gender:M
Credentials:MSW, LCSW-SAS, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 WEST POINT RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304
Mailing Address - Country:US
Mailing Address - Phone:920-490-3790
Mailing Address - Fax:920-490-3889
Practice Address - Street 1:2640 WEST POINT RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304
Practice Address - Country:US
Practice Address - Phone:920-490-3790
Practice Address - Fax:920-490-3889
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7420-123101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
12435121OtherCAQH
WI100022647Medicaid