Provider Demographics
NPI:1205119633
Name:STRACK, BENJAMIN WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:STRACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2668 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5402
Mailing Address - Country:US
Mailing Address - Phone:949-722-7805
Mailing Address - Fax:
Practice Address - Street 1:23 CORPORATE PLAZA DR STE 150
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7908
Practice Address - Country:US
Practice Address - Phone:949-629-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24425103TB0200X, 103T00000X, 103TC2200X, 103TF0000X, 103TH0004X, 103TC0700X
PSY 24425103TE1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth