Provider Demographics
NPI:1770214744
Name:BENNER, LAIZA K
Entity Type:Individual
Prefix:
First Name:LAIZA
Middle Name:K
Last Name:BENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N MIDVALE BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3265
Mailing Address - Country:US
Mailing Address - Phone:608-852-8585
Mailing Address - Fax:
Practice Address - Street 1:310 N MIDVALE BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3265
Practice Address - Country:US
Practice Address - Phone:608-852-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool