Provider Demographics
NPI:1225404544
Name:JUDY BANNISTER, LLC
Entity Type:Organization
Organization Name:JUDY BANNISTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BANNISTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCAC, SAP, NCC
Authorized Official - Phone:317-670-9413
Mailing Address - Street 1:5455 W 86TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1536
Mailing Address - Country:US
Mailing Address - Phone:317-762-0888
Mailing Address - Fax:
Practice Address - Street 1:5455 W 86TH ST STE 102
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1536
Practice Address - Country:US
Practice Address - Phone:317-762-0888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001400A101YA0400X
IN34004283A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ2917Medicare PIN