MEDICARE: BENJIMEN C WEIDMAN

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
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1760009443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJIMEN C WEIDMAN

Provider Business Mailing Address
First Line	:	55 E COLORADO BLVD STE 560
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91105-1901
Country	:	US
Telephone Number	:	818-214-6780
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 E COLORADO BLVD STE 560
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91105-1901
Country	:	US
Telephone Number	:	818-214-6780
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2020
Last Update Date	:	06/29/2020

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Directions to “ BENJIMEN C WEIDMAN ” Practice Location

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