Provider Demographics
NPI:1154614535
Name:FISHBURNE, BENJAMIN POSTELL IV (MFT)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:POSTELL
Last Name:FISHBURNE
Suffix:IV
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6046 CAMINO RICO
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3033
Mailing Address - Country:US
Mailing Address - Phone:619-272-3193
Mailing Address - Fax:
Practice Address - Street 1:6046 CAMINO RICO
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3033
Practice Address - Country:US
Practice Address - Phone:619-272-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42328106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist