Healthcare Provider Details

I. General information

NPI: 1174033708
Provider Name (Legal Business Name): MRS. DEIDRE JOY BANAHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2017
Last Update Date: 10/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1913 M ST
BELLEVILLE KS
66935-2238
US

IV. Provider business mailing address

205 BEACH ST
CUBA KS
66940-3000
US

V. Phone/Fax

Practice location:
  • Phone: 785-955-2233
  • Fax:
Mailing address:
  • Phone: 785-955-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3225
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: