Provider Demographics
NPI:1144600149
Name:BANASZAK, CARRIE JEAN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:JEAN
Last Name:BANASZAK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2831
Mailing Address - Country:US
Mailing Address - Phone:920-770-4088
Mailing Address - Fax:
Practice Address - Street 1:123 N OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2831
Practice Address - Country:US
Practice Address - Phone:920-770-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2259-226101YP2500X
WI6867-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100055240Medicaid