Provider Demographics
NPI:1558581579
Name:BANASIAK, JULIE V
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:V
Last Name:BANASIAK
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 1:527 NW EMBER WAY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3521
Mailing Address - Country:US
Mailing Address - Phone:772-232-9515
Mailing Address - Fax:772-232-9521
Practice Address - Street 1:3496 NW FEDERAL HWY STE G
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4441
Practice Address - Country:US
Practice Address - Phone:772-223-5945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6855235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist