Provider Demographics
NPI:1760197339
Name:ERNSBERGER, BENJAMIN JOEL
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOEL
Last Name:ERNSBERGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 HIGH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3719
Mailing Address - Country:US
Mailing Address - Phone:231-939-1045
Mailing Address - Fax:
Practice Address - Street 1:2236 E MITCHELL RD # 5
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9604
Practice Address - Country:US
Practice Address - Phone:231-939-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022702101Y00000X
MI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MINONEOtherHEALTHCARE