Healthcare Provider Details

I. General information

NPI: 1770037632
Provider Name (Legal Business Name): BENJAMIN METTA PENHAS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9666 BUSINESSPARK AVE
SAN DIEGO CA
92131-1646
US

IV. Provider business mailing address

4745 W PARK BLVD STE113-1058
PLANO TX
75093-2329
US

V. Phone/Fax

Practice location:
  • Phone: 619-600-0073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32888
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: