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General NPI Number Information
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NPI Number | 1659057446
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Entity Type | Individual
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Provider Name | BENJAMIN I DE BOER PSYD
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Gender | Male
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Dates
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Enumeration Date | 06/26/2023
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Last Update Date | 12/18/2025
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Provider Practice Location Address
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Address Line | 2921 LANDMARK PL STE 215
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City | MADISON
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State | WI
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Zip | 53713-4248
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Country | US
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Telephone | 401-864-6246
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Fax |
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Provider Business Mailing Address
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Address Line | 2824 FRISEE DR
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City | FITCHBURG
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State | WI
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Zip | 53711-8502
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Country | US
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Telephone | 401-864-6246
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 3452-57
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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