Healthcare Provider Details

I. General information

NPI: 1528113727
Provider Name (Legal Business Name): GERARD A BANEZ PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MARTIN LUTHER KING JR DR
CLEVELAND OH
44104-3815
US

IV. Provider business mailing address

2801 MARTIN LUTHER KING JR DR
CLEVELAND OH
44104-3815
US

V. Phone/Fax

Practice location:
  • Phone: 216-448-6253
  • Fax: 216-448-6207
Mailing address:
  • Phone: 216-448-6253
  • Fax: 216-448-6207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number5571
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number5571
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5571
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: