Provider Demographics
NPI:1336415421
Name:KEIZER, BENJAMIN M (PHD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:KEIZER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 ROGER BROOKE DR
Mailing Address - Street 2:MCHE-QD (CREDS)
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4501
Mailing Address - Country:US
Mailing Address - Phone:210-916-2460
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:MCHE-QD (CREDS)
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:210-916-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY130005103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical