Provider Demographics
NPI:1518300672
Name:BANNISTER, JUDY A (LCSW, LCAC, SAP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:LCSW, LCAC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 W 86TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1536
Mailing Address - Country:US
Mailing Address - Phone:317-762-0888
Mailing Address - Fax:317-203-0983
Practice Address - Street 1:5455W 86TH ST 102
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1536
Practice Address - Country:US
Practice Address - Phone:317-762-0888
Practice Address - Fax:317-203-0983
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001400A101YA0400X
IN34004283A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)