Provider Demographics
NPI:1174076954
Name:MCKENNA, BENJAMIN (PHD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MCKENNA
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 1:3252 HOLIDAY CT
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-0027
Mailing Address - Country:US
Mailing Address - Phone:858-534-8817
Mailing Address - Fax:858-534-9410
Practice Address - Street 1:3252 HOLIDAY CT
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0027
Practice Address - Country:US
Practice Address - Phone:858-534-8817
Practice Address - Fax:858-534-9410
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26510103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical