Provider Demographics
NPI:1619741006
Name:LEDDICK, BENJAMIN (AMFT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LEDDICK
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 3/4 MIRA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1868
Mailing Address - Country:US
Mailing Address - Phone:720-937-1078
Mailing Address - Fax:
Practice Address - Street 1:1150 FOOTHILL BLVD STE D
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-3269
Practice Address - Country:US
Practice Address - Phone:818-960-6908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142663106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist