Provider Demographics
NPI:1336353689
Name:BENAU, KENNETH S (PHD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:BENAU
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 1:1315 HOLMAN RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2542
Mailing Address - Country:US
Mailing Address - Phone:510-763-8501
Mailing Address - Fax:510-763-8501
Practice Address - Street 1:376 COLUSA AVE STE 2
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CA
Practice Address - Zip Code:94707-1213
Practice Address - Country:US
Practice Address - Phone:510-525-3702
Practice Address - Fax:510-763-8501
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11684103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical