Healthcare Provider Details

I. General information

NPI: 1851540702
Provider Name (Legal Business Name): GARRET BENJAMIN WYNER PHD, PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12944 GREENLEAF ST
STUDIO CITY CA
91604-2224
US

IV. Provider business mailing address

12944 GREENLEAF ST
STUDIO CITY CA
91604-2224
US

V. Phone/Fax

Practice location:
  • Phone: 818-784-4784
  • Fax: 818-784-7922
Mailing address:
  • Phone: 818-784-4784
  • Fax: 818-784-7922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number27475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: