Provider Demographics
NPI:1962610303
Name:BANASZAK, MARY T
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BANASZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 RIVER TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-1802
Mailing Address - Country:US
Mailing Address - Phone:989-892-9071
Mailing Address - Fax:989-892-9018
Practice Address - Street 1:2501 CENTER AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6382
Practice Address - Country:US
Practice Address - Phone:989-892-9071
Practice Address - Fax:989-892-9018
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health