Provider Demographics
NPI:1679844898
Name:PEERBOLT, BENJAMIN (LCSW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:PEERBOLT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 N 63RD ST
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-2811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5420 W STATE ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-2514
Practice Address - Country:US
Practice Address - Phone:414-509-7060
Practice Address - Fax:414-509-7388
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical