Provider Demographics
NPI:1588808281
Name:BANIC, DIANE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:M
Last Name:BANIC
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 TAYLOR WOOD RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40067-6635
Mailing Address - Country:US
Mailing Address - Phone:502-777-7339
Mailing Address - Fax:
Practice Address - Street 1:1219 TAYLORWOOD RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:KY
Practice Address - Zip Code:40067
Practice Address - Country:US
Practice Address - Phone:502-777-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0830103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist