Provider Demographics
NPI:1437645843
Name:BANISTER, KRISTEN (LPC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BANISTER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:WIDMARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:619 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85705-8340
Mailing Address - Country:US
Mailing Address - Phone:928-225-1845
Mailing Address - Fax:
Practice Address - Street 1:1601 N TUCSON BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-3425
Practice Address - Country:US
Practice Address - Phone:928-225-1845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17056101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor