Basic Information
| Provider Information | |||||||||
| NPI: | 1083011829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANISTER | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 S LAPEER RD | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483716108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489699932 | ||||||||
| FaxNumber: | 2489690840 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 LAPEER RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102327919 | ||||||||
| FaxNumber: | 8102327913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2014 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 6802086581 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.