Provider Demographics
NPI:1053510321
Name:BENJAMIN, KENNY (MFT)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4271 KENYON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6124
Mailing Address - Country:US
Mailing Address - Phone:310-780-3830
Mailing Address - Fax:
Practice Address - Street 1:1317 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:S PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4511
Practice Address - Country:US
Practice Address - Phone:323-344-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7184OtherMEDI-CAL
CA7667OtherMEDI-CAL