Provider Demographics
NPI:1639200769
Name:WILSON, BENJAMIN (LMFT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 E PACIFIC COAST HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3394
Mailing Address - Country:US
Mailing Address - Phone:562-490-7669
Mailing Address - Fax:
Practice Address - Street 1:5150 E PACIFIC COAST HWY STE 100
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3394
Practice Address - Country:US
Practice Address - Phone:562-490-7669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT46444106H00000X
CALMFT 46444106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist