Healthcare Provider Details

I. General information

NPI: 1073228698
Provider Name (Legal Business Name): JOSEPH BEENEY PH D PSYCHOLOGIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N MAIN ST
FORT BRAGG CA
95437-3220
US

IV. Provider business mailing address

720 N HARRISON ST
FORT BRAGG CA
95437-3125
US

V. Phone/Fax

Practice location:
  • Phone: 707-421-8884
  • Fax:
Mailing address:
  • Phone: 707-421-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH EDWARD BEENEY
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 707-972-5089