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General NPI Number Information
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NPI Number | 1578908752
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Entity Type | Individual
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Provider Name | LISA BANASIAK
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Gender | Female
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Dates
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Enumeration Date | 05/01/2013
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Last Update Date | 05/01/2013
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Provider Practice Location Address
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Address Line | 7130 MAGNOLIA AVE STE. R
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City | RIVERSIDE
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State | CA
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Zip | 92504-3864
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Country | US
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Telephone | 951-213-6742
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Fax | 951-534-0551
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Provider Business Mailing Address
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Address Line | 7130 MAGNOLIA AVE STE. R
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City | RIVERSIDE
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State | CA
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Zip | 92504-3864
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | PCI 208
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License Number State | CA
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