Provider Demographics
NPI:1629368204
Name:BECKER, BENNJAMIN FULTON (PLADC)
Entity Type:Individual
Prefix:
First Name:BENNJAMIN
Middle Name:FULTON
Last Name:BECKER
Suffix:
Gender:M
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 RIDGE PARK DR APT 133
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68504-4662
Mailing Address - Country:US
Mailing Address - Phone:402-730-4074
Mailing Address - Fax:
Practice Address - Street 1:721 K ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68508-2949
Practice Address - Country:US
Practice Address - Phone:402-477-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-973101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)