Provider Demographics
NPI:1093320608
Name:BANAS, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BANAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40723 93RD ST
Mailing Address - Street 2:
Mailing Address - City:GENOA CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53128-1291
Mailing Address - Country:US
Mailing Address - Phone:219-476-5863
Mailing Address - Fax:
Practice Address - Street 1:750 VETERANS PKWY UNIT 100
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4950
Practice Address - Country:US
Practice Address - Phone:262-248-7942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health