Provider Demographics
NPI:1295358901
Name:BENJAMIN BRAAKSMA
Entity type:Organization
Organization Name:BENJAMIN BRAAKSMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAAKSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-945-0648
Mailing Address - Street 1:1115 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-2690
Mailing Address - Country:US
Mailing Address - Phone:206-945-0648
Mailing Address - Fax:206-834-6734
Practice Address - Street 1:1115 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2690
Practice Address - Country:US
Practice Address - Phone:206-945-0648
Practice Address - Fax:206-834-6734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH60891645OtherLICENSE
OHE.2303894OtherLICENSE