Provider Demographics
NPI:1376662650
Name:BENSON, GORDON L (PHD)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:L
Last Name:BENSON
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 1:545 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-4727
Mailing Address - Country:US
Mailing Address - Phone:978-342-0685
Mailing Address - Fax:975-342-8495
Practice Address - Street 1:545 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4727
Practice Address - Country:US
Practice Address - Phone:978-342-0685
Practice Address - Fax:975-342-8495
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6718103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5OtherMARRIAGE & FAMILY THERAPY
MD6718OtherPSYCHOLOGY LICD
MD6718OtherPSYCHOLOGY LICD