Provider Demographics
NPI:1558988758
Name:BANISAID, LINDA T
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:T
Last Name:BANISAID
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 1:5257 BIG TYLER RD
Mailing Address - Street 2:
Mailing Address - City:CROSS LANES
Mailing Address - State:WV
Mailing Address - Zip Code:25313-1839
Mailing Address - Country:US
Mailing Address - Phone:304-823-2937
Mailing Address - Fax:
Practice Address - Street 1:5257 BIG TYLER RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1839
Practice Address - Country:US
Practice Address - Phone:681-217-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00945543104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker