Provider Demographics
NPI:1477021814
Name:BANATTE, THAINA
Entity Type:Individual
Prefix:
First Name:THAINA
Middle Name:
Last Name:BANATTE
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 1:21730 HOLLIS AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1951
Mailing Address - Country:US
Mailing Address - Phone:917-570-9877
Mailing Address - Fax:
Practice Address - Street 1:21730 HOLLIS AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1951
Practice Address - Country:US
Practice Address - Phone:917-570-9877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105344104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY105344OtherLICENSURE