Provider Demographics
NPI:1417127218
Name:BANASZAK, MARK STEPHEN (LMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEPHEN
Last Name:BANASZAK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 BALSAM FIR CT
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9150
Mailing Address - Country:US
Mailing Address - Phone:716-864-9079
Mailing Address - Fax:
Practice Address - Street 1:6321 BALSAM FIR CT
Practice Address - Street 2:
Practice Address - City:CLARENCE CENTER
Practice Address - State:NY
Practice Address - Zip Code:14032-9150
Practice Address - Country:US
Practice Address - Phone:716-864-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist