Provider Demographics
NPI:1104042654
Name:BANNERMAN, LINDA J (MA)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:J
Last Name:BANNERMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 N COLUMBIA HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-9514
Mailing Address - Country:US
Mailing Address - Phone:360-577-0789
Mailing Address - Fax:
Practice Address - Street 1:42 ELOCHOMAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:CATHLAMET
Practice Address - State:WA
Practice Address - Zip Code:98612-9602
Practice Address - Country:US
Practice Address - Phone:360-795-8630
Practice Address - Fax:360-795-6224
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00003433101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARC00003433OtherREGISTERED COUNSELOR