MEDICARE: BANAITIS INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-16-24542	CA
2	1041C0700X	Clinical Social Worker
3	106H00000X	Marriage & Family Therapist	LMFT 47513	CA
4	252Y00000X	Early Intervention Provider Agency	PW5642	CA
5	106H00000X	Marriage & Family Therapist	MFC 44723	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	493372	OTHER		MHN PROVIDER ID
2	A4793432	OTHER	CA	AETNA PROVIDER PIN
3	PW5642	OTHER	CA	DEPT. OF DEVELOPMENTAL SERVICES (HHS) AGENCY VENDOR NO.

General Provider Information

NPI Number	:	1346520459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BANAITIS INC.

Provider Business Mailing Address
First Line	:	12100 WILSHIRE BLVD
Second Line	:	SUITE 800
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-7120
Country	:	US
Telephone Number	:	310-775-1521
Fax Number	:	424-238-8394

Provider Business Practice Location Address
First Line	:	12100 WILSHIRE BLVD
Second Line	:	SUITE 800
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-7120
Country	:	US
Telephone Number	:	310-775-1521
Fax Number	:	424-238-8394

Authorized Official
Title or Position	:	PRESIDENT/PROGRAM DIRECTOR
Name	:	DANIEL JOESPH BANAITIS
Credential	:	M.A., LMFT
Telephone Number	:	310-775-1521

Provider Enumeration Date	:	08/19/2011
Last Update Date	:	12/01/2020

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Directions to “BANAITIS INC. ” Practice Location

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