Provider Demographics
NPI:1083011829
Name:BANISTER, MARLA LYNN (BSW, CMHP, QMHP)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:LYNN
Last Name:BANISTER
Suffix:
Gender:F
Credentials:BSW, CMHP, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0289
Mailing Address - Country:US
Mailing Address - Phone:517-676-5405
Mailing Address - Fax:517-676-5460
Practice Address - Street 1:6211 TAYLOR DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4665
Practice Address - Country:US
Practice Address - Phone:810-237-0799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 171M00000X
MI68020865811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical