Provider Demographics
NPI:1285302372
Name:JOHNIDES, BENJAMIN DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:JOHNIDES
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 1:210 SOUTH ORANGE GROVE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91123-1912
Mailing Address - Country:US
Mailing Address - Phone:805-409-7462
Mailing Address - Fax:
Practice Address - Street 1:210 SOUTH ORANGE GROVE BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91123-2211
Practice Address - Country:US
Practice Address - Phone:805-409-7462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024445103TC0700X
CA35091103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical