Provider Demographics
NPI:1477904522
Name:FELLEMAN, BENJAMIN ISAAC (PHD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:ISAAC
Last Name:FELLEMAN
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 1:5405 MOREHOUSE DR
Mailing Address - Street 2:STE 120
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4723
Mailing Address - Country:US
Mailing Address - Phone:713-826-1350
Mailing Address - Fax:858-408-9422
Practice Address - Street 1:5405 MOREHOUSE DR
Practice Address - Street 2:STE 120
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4723
Practice Address - Country:US
Practice Address - Phone:713-826-1350
Practice Address - Fax:858-408-9422
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28401103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13851419OtherCAQH