Provider Demographics
NPI:1033442843
Name:THOMPSON, BENLEY STEVENSON (MA)
Entity Type:Individual
Prefix:MR
First Name:BENLEY
Middle Name:STEVENSON
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 JEROME ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-6711
Mailing Address - Country:US
Mailing Address - Phone:857-251-0013
Mailing Address - Fax:781-483-3740
Practice Address - Street 1:1960 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02118-3219
Practice Address - Country:US
Practice Address - Phone:617-516-0280
Practice Address - Fax:617-516-0281
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA452055800OtherBHL PROVIDER NUMBER