Provider Demographics
NPI:1578204301
Name:BANACH, LYDIA IRENE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:IRENE
Last Name:BANACH
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 1:1301 MILLER TRUNK HWY STE 500
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5644
Mailing Address - Country:US
Mailing Address - Phone:218-481-7290
Mailing Address - Fax:218-481-7263
Practice Address - Street 1:1301 MILLER TRUNK HWY STE 500
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5644
Practice Address - Country:US
Practice Address - Phone:218-481-7290
Practice Address - Fax:218-481-7263
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician