Provider Demographics
NPI:1205545464
Name:BRIESATH, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BRIESATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 SCHROEDER CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2503
Mailing Address - Country:US
Mailing Address - Phone:608-270-2511
Mailing Address - Fax:608-270-0467
Practice Address - Street 1:26 SCHROEDER CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2503
Practice Address - Country:US
Practice Address - Phone:608-270-2511
Practice Address - Fax:608-270-0467
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI134945-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker