Provider Demographics
NPI:1235250168
Name:BANASIAK, MORGAN ANN (MSED)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:ANN
Last Name:BANASIAK
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-5158
Mailing Address - Country:US
Mailing Address - Phone:630-816-7034
Mailing Address - Fax:630-562-2550
Practice Address - Street 1:630 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:WEST CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60185-5158
Practice Address - Country:US
Practice Address - Phone:630-816-7034
Practice Address - Fax:630-562-2550
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMB79950898POtherE.I. CREDENTIAL