Basic Information
| Provider Information | |||||||||
| NPI: | 1003284001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | BENJAMIN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 654 BEACON ST 2 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022152099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175361161 | ||||||||
| FaxNumber: | 6175361165 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 MILTON ST | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024748705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6415210012 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2015 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 21979 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.