Provider Demographics
NPI:1194348458
Name:PEACEFUL BANYAN
Entity type:Organization
Organization Name:PEACEFUL BANYAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS LLP
Authorized Official - Phone:248-444-5479
Mailing Address - Street 1:409 PLYMOUTH RD STE 270
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1842
Mailing Address - Country:US
Mailing Address - Phone:248-444-5479
Mailing Address - Fax:
Practice Address - Street 1:409 PLYMOUTH RD STE 270
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1842
Practice Address - Country:US
Practice Address - Phone:248-444-5479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty