Basic Information
| Provider Information | |||||||||
| NPI: | 1730306754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593015901 | ||||||||
| FaxNumber: | 8593015940 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 GRAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 41071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593015901 | ||||||||
| FaxNumber: | 8593015940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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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 | 103TC0700X | 71007260 | IL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 128177 | KY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | K237430 | 01 | KY | KY MEDICARE | OTHER | 7100501510 | 05 | KY | MEDICAID |