Provider Demographics
NPI:1558387902
Name:D'ANGELO, BENJAMIN ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:D'ANGELO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:WI
Mailing Address - Zip Code:53015-1413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 NORTH AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:WI
Practice Address - Zip Code:53015-1413
Practice Address - Country:US
Practice Address - Phone:920-693-5600
Practice Address - Fax:920-693-5604
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2586-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical