Healthcare Provider Details

I. General information

NPI: 1205119633
Provider Name (Legal Business Name): BENJAMIN WILLIAM STRACK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 12/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 CORPORATE PLAZA DR STE 150
NEWPORT BEACH CA
92660-7908
US

IV. Provider business mailing address

2668 S GRAND AVE
SANTA ANA CA
92705-5402
US

V. Phone/Fax

Practice location:
  • Phone: 949-629-2560
  • Fax:
Mailing address:
  • Phone: 949-722-7805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY 24425
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY 24425
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY 24425
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License NumberPSY 24425
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPSY 24425
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY 24425
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 24425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: