Provider Demographics
NPI:1073128559
Name:BENSON, WILLIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:
Last Name:BENSON
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 1:7373 UNIVERSITY AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-0524
Mailing Address - Country:US
Mailing Address - Phone:619-825-8388
Mailing Address - Fax:619-825-6878
Practice Address - Street 1:7373 UNIVERSITY AVE STE 201
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-0524
Practice Address - Country:US
Practice Address - Phone:619-825-8388
Practice Address - Fax:619-825-6878
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8975101Y00000X, 101YP1600X, 374K00000X, 101YM0800X
CA182820120101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner