Provider Demographics
NPI:1700502960
Name:CALVERT MASON, BENJAMIN BRENT (LPC-IT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRENT
Last Name:CALVERT MASON
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E WASHINGTON ST STE 2100
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2503
Mailing Address - Country:US
Mailing Address - Phone:262-335-4584
Mailing Address - Fax:262-335-6827
Practice Address - Street 1:333 E WASHINGTON ST STE 2100
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2503
Practice Address - Country:US
Practice Address - Phone:262-335-4584
Practice Address - Fax:262-335-6827
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7120-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional