Provider Demographics
NPI:1003284001
Name:GIBSON, BENJAMIN (DPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:654 BEACON ST 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-2099
Mailing Address - Country:US
Mailing Address - Phone:617-536-1161
Mailing Address - Fax:617-536-1165
Practice Address - Street 1:43 MILTON ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-8705
Practice Address - Country:US
Practice Address - Phone:641-521-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist