Provider Demographics
NPI:1053658377
Name:RICHTER, BENJAMIN JOSEPH (PSYD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JOSEPH
Last Name:RICHTER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:515 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-3167
Mailing Address - Country:US
Mailing Address - Phone:309-655-7378
Mailing Address - Fax:309-655-4609
Practice Address - Street 1:515 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-3167
Practice Address - Country:US
Practice Address - Phone:309-655-7378
Practice Address - Fax:309-655-4609
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008614103G00000X
AZ4350103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical