Basic Information
| Provider Information | |||||||||
| NPI: | 1477727097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHENEY | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSW, LCSW-SAS, CCTP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2640 WEST POINT RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204903790 | ||||||||
| FaxNumber: | 9204903889 | ||||||||
| Practice Location | |||||||||
| Address1: | 2640 WEST POINT RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204903790 | ||||||||
| FaxNumber: | 9204903889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2008 | ||||||||
| LastUpdateDate: | 09/16/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 7420-123 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 7420-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 12435121 | 01 | CAQH | OTHER | 100022647 | 05 | WI | MEDICAID |