Provider Demographics
NPI:1407905995
Name:WILLIS, BENNY S (PHD)
Entity Type:Individual
Prefix:DR
First Name:BENNY
Middle Name:S
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:B
Other - Middle Name:STEVEN
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:691 MASSACHUSSETS AVENUE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02479-1648
Mailing Address - Country:US
Mailing Address - Phone:617-242-4228
Mailing Address - Fax:
Practice Address - Street 1:691 MASSACHUSSETS AVENUE
Practice Address - Street 2:SUITE 10
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02479-1648
Practice Address - Country:US
Practice Address - Phone:617-242-4228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6244103TB0200X, 103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO4947OtherBLUE CROSS BLUE SHIELD
MAWO4947Medicare ID - Type Unspecified