Provider Demographics
NPI:1063673374
Name:HAVENS BANNER, ANNA MICHELLE (STA)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MICHELLE
Last Name:HAVENS BANNER
Suffix:
Gender:F
Credentials:STA
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:BANNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5507 SW 9TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106
Mailing Address - Country:US
Mailing Address - Phone:806-468-7611
Mailing Address - Fax:806-468-7603
Practice Address - Street 1:5507 SW 9TH AVENUE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106
Practice Address - Country:US
Practice Address - Phone:806-468-7611
Practice Address - Fax:806-468-7603
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342532355S0801X
TX0217267-012355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0217267-01Medicaid