MEDICARE: ALICIA BANISTER

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	225700000X	Massage Therapist	21093	OR
2	101YM0800X	Mental Health Counselor	C6803	OR

General Provider Information

NPI Number	:	1649668138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA BANISTER

Provider Business Mailing Address
First Line	:	3930 SE IVON ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-1651
Country	:	US
Telephone Number	:	503-893-2067
Fax Number	:

Provider Business Practice Location Address
First Line	:	3930 SE IVON ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-1651
Country	:	US
Telephone Number	:	503-893-2067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2015
Last Update Date	:	08/24/2023

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Directions to “ ALICIA BANISTER ” Practice Location

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