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NPI Code Detail

MEDICARE: DR. BENJAMIN WILLIAM STRACK PH.D.

MEDICARE: DR. BENJAMIN WILLIAM STRACK PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TB0200XCognitive & Behavioral PsychologistPSY 24425CA
2103T00000XPsychologistPSY 24425CA
3103TC2200XClinical Child & Adolescent PsychologistPSY 24425CA
4103TE1100XExercise & Sports PsychologistPSY 24425
5103TF0000XFamily PsychologistPSY 24425CA
6103TH0004XHealth PsychologistPSY 24425CA
7103TC0700XClinical PsychologistPSY 24425CA

General Provider Information

NPI Number : 1205119633
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BENJAMIN WILLIAM STRACK PH.D.
Provider Business Mailing Address
First Line : 2668 S GRAND AVE
Second Line :
City : SANTA ANA
State : CA
Zip : 92705-5402
Country : US
Telephone Number : 949-722-7805
Fax Number :
Provider Business Practice Location Address
First Line : 23 CORPORATE PLAZA DR STE 150
Second Line :
City : NEWPORT BEACH
State : CA
Zip : 92660-7908
Country : US
Telephone Number : 949-629-2560
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/22/2011
Last Update Date : 12/14/2018

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