Healthcare Provider Details

I. General information

NPI: 1588583157
Provider Name (Legal Business Name): ASHLEY BANACH MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

IV. Provider business mailing address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-5535
  • Fax: 313-831-2608
Mailing address:
  • Phone: 313-831-5535
  • Fax: 313-831-2608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number6352001160
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: