Provider Demographics
NPI:1457535825
Name:WALLMAN, BENJAMIN M
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:M
Last Name:WALLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-0051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1722 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-766-8492
Practice Address - Fax:805-739-8863
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148757106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist