Provider Demographics
NPI:1154515237
Name:BANISTER, BENJAMIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:BANISTER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 JUNCTION SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-3049
Mailing Address - Country:US
Mailing Address - Phone:978-254-0123
Mailing Address - Fax:
Practice Address - Street 1:1218 MASSACHUSETTS AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-855-2711
Practice Address - Fax:617-855-3730
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8748103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical