Provider Demographics
NPI:1699586842
Name:BANACH, DAVID G (LGPC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:BANACH
Suffix:
Gender:M
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 DORCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-4703
Mailing Address - Country:US
Mailing Address - Phone:443-477-0918
Mailing Address - Fax:
Practice Address - Street 1:815 RITCHIE HWY STE 205
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-4164
Practice Address - Country:US
Practice Address - Phone:443-477-0918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15830101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health