MEDICARE: MARY T BANASZAK

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1962610303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY T BANASZAK

Provider Business Mailing Address
First Line	:	27 RIVER TRAIL DR
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-1802
Country	:	US
Telephone Number	:	989-892-9071
Fax Number	:	989-892-9018

Provider Business Practice Location Address
First Line	:	2501 CENTER AVE
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48708-6382
Country	:	US
Telephone Number	:	989-892-9071
Fax Number	:	989-892-9018

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

Provider Enumeration Date	:	05/18/2007
Last Update Date	:	07/08/2007

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Directions to “ MARY T BANASZAK ” Practice Location

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