Healthcare Provider Details

I. General information

NPI: 1043166325
Provider Name (Legal Business Name): BENJAMIN THOMAS VANDERVEST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 COHO ST STE 202
MADISON WI
53713-4531
US

IV. Provider business mailing address

8551 GREENWAY BLVD APT 308
MIDDLETON WI
53562-4678
US

V. Phone/Fax

Practice location:
  • Phone: 608-616-0157
  • Fax:
Mailing address:
  • Phone: 608-772-6515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: