Provider Demographics
NPI:1710716444
Name:VONDERSCHMITT, BENJAMIN TRISTAN (PSYS)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:TRISTAN
Last Name:VONDERSCHMITT
Suffix:
Gender:M
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 SAINT CHARLES ST STE 2
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-1878
Mailing Address - Country:US
Mailing Address - Phone:502-314-5966
Mailing Address - Fax:
Practice Address - Street 1:1520 SAINT CHARLES ST STE 2
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1878
Practice Address - Country:US
Practice Address - Phone:502-314-5966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10089092103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool