Healthcare Provider Details

I. General information

NPI: 1295990992
Provider Name (Legal Business Name): BENJAMIN WILSON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 MYERS ST STE 2
RIVERSIDE CA
92503-5527
US

IV. Provider business mailing address

9890 COUNTY FARM RD
RIVERSIDE CA
92503-3505
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4840
  • Fax: 951-358-4848
Mailing address:
  • Phone: 951-358-4840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY25427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: