Healthcare Provider Details

I. General information

NPI: 1023687068
Provider Name (Legal Business Name): BENJAMIN RUSSELL FIENUP MC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 ELMRIDGE DR
CEDAR FALLS IA
50613-5404
US

IV. Provider business mailing address

1203 ELMRIDGE DR
CEDAR FALLS IA
50613-5404
US

V. Phone/Fax

Practice location:
  • Phone: 319-504-5982
  • Fax:
Mailing address:
  • Phone: 319-504-5982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number108949
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: