Provider Demographics
NPI:1518097302
Name:BANIAK, MARY J (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:BANIAK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 5 BOX 521
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-9016
Mailing Address - Country:US
Mailing Address - Phone:301-707-3346
Mailing Address - Fax:304-726-4213
Practice Address - Street 1:RR 5 BOX 521
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-9016
Practice Address - Country:US
Practice Address - Phone:301-707-3346
Practice Address - Fax:304-726-4213
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVBA4175931Medicare ID - Type UnspecifiedPHYSICAL THERAPIST