Provider Demographics
NPI:1205140746
Name:KILLILEA, BENJAMIN (PHD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:KILLILEA
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 1:39 BOTOLPH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-1988
Mailing Address - Country:US
Mailing Address - Phone:339-987-0849
Mailing Address - Fax:
Practice Address - Street 1:75 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6103
Practice Address - Country:US
Practice Address - Phone:617-626-9318
Practice Address - Fax:617-626-9531
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8993103T00000X
103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent