Provider Demographics
NPI:1659057446
Name:DE BOER, BENJAMIN I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:I
Last Name:DE BOER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 FRISEE DR
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711
Mailing Address - Country:US
Mailing Address - Phone:401-864-6246
Mailing Address - Fax:
Practice Address - Street 1:2824 FRISEE DR
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711
Practice Address - Country:US
Practice Address - Phone:401-864-6246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TP2701X
WI3452-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy