Provider Demographics
NPI:1528113727
Name:BANEZ, GERARD A (PHD)
Entity type:Individual
Prefix:
First Name:GERARD
Middle Name:A
Last Name:BANEZ
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 1:2801 MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3815
Mailing Address - Country:US
Mailing Address - Phone:216-448-6253
Mailing Address - Fax:216-448-6207
Practice Address - Street 1:2801 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3815
Practice Address - Country:US
Practice Address - Phone:216-448-6253
Practice Address - Fax:216-448-6207
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5571103TC2200X, 103TH0004X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2167319Medicaid
OHS86203Medicare UPIN
OH2167319Medicaid