Provider Demographics
NPI:1174033708
Name:BANAHAN, DEIDRE JOY
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:JOY
Last Name:BANAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 BEACH ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:KS
Mailing Address - Zip Code:66940-3000
Mailing Address - Country:US
Mailing Address - Phone:785-955-2233
Mailing Address - Fax:
Practice Address - Street 1:1913 M ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:KS
Practice Address - Zip Code:66935-2238
Practice Address - Country:US
Practice Address - Phone:785-955-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3225225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist