Healthcare Provider Details

I. General information

NPI: 1154515237
Provider Name (Legal Business Name): BENJAMIN BANISTER PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 MAIN ST STE 324
CONCORD MA
01742-3329
US

IV. Provider business mailing address

747 MAIN ST STE 324
CONCORD MA
01742-3329
US

V. Phone/Fax

Practice location:
  • Phone: 978-405-2521
  • Fax:
Mailing address:
  • Phone: 978-405-2521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number8748
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: