Provider Demographics
NPI:1578013744
Name:LORD, BENJAMIN DYSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DYSON
Last Name:LORD
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 1:13515 LAKE TERRACE LN
Mailing Address - Street 2:ALPHA CLINIC
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-1003
Mailing Address - Country:US
Mailing Address - Phone:813-998-8000
Mailing Address - Fax:
Practice Address - Street 1:13515 LAKE TERRACE LN
Practice Address - Street 2:ALPHA CLINIC
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33637-1003
Practice Address - Country:US
Practice Address - Phone:813-998-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical