Provider Demographics
NPI:1497108203
Name:BANHAM, ALYSSA (LMSW)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:BANHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 CAMINO LA COSTA
Mailing Address - Street 2:APT 1901
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752-3846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13207 WRIGHT RD
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-5000
Practice Address - Country:US
Practice Address - Phone:512-697-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-16
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62525104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker