Provider Demographics
NPI:1669200093
Name:WALL, BENJAMIN NISHAN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:NISHAN
Last Name:WALL
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 1:3657 N WHIPPLE ST APT 1F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4519
Mailing Address - Country:US
Mailing Address - Phone:559-799-1139
Mailing Address - Fax:
Practice Address - Street 1:415 WASHINGTON ST STE 200
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5564
Practice Address - Country:US
Practice Address - Phone:847-441-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical