Healthcare Provider Details

I. General information

NPI: 1659057446
Provider Name (Legal Business Name): BENJAMIN I DE BOER PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 LANDMARK PL STE 215
MADISON WI
53713-4248
US

IV. Provider business mailing address

2824 FRISEE DR
FITCHBURG WI
53711-8502
US

V. Phone/Fax

Practice location:
  • Phone: 401-864-6246
  • Fax:
Mailing address:
  • Phone: 401-864-6246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3452-57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: