Provider Demographics
NPI:1366178634
Name:FOSTER, BENJAMIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:FOSTER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 N LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5300
Mailing Address - Country:US
Mailing Address - Phone:872-216-7376
Mailing Address - Fax:
Practice Address - Street 1:3660 N LAKE SHORE DR STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-5302
Practice Address - Country:US
Practice Address - Phone:872-216-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010805103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical