Provider Demographics
NPI:1386805315
Name:BANNISTER, CHASE TODD (MDIV MSW LCSW CEDS)
Entity type:Individual
Prefix:MR
First Name:CHASE
Middle Name:TODD
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:MDIV MSW LCSW CEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 STUART DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2262
Mailing Address - Country:US
Mailing Address - Phone:202-670-5125
Mailing Address - Fax:
Practice Address - Street 1:817 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4137
Practice Address - Country:US
Practice Address - Phone:202-670-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0060861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical