Provider Demographics
NPI:1689663072
Name:BANISTER, SUE (MS)
Entity Type:Individual
Prefix:MRS
First Name:SUE
Middle Name:
Last Name:BANISTER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 POPLAR AVE
Mailing Address - Street 2:SUITE 730
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3699
Mailing Address - Country:US
Mailing Address - Phone:901-683-5658
Mailing Address - Fax:901-684-1277
Practice Address - Street 1:5350 POPLAR AVE
Practice Address - Street 2:SUITE 730
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3699
Practice Address - Country:US
Practice Address - Phone:901-683-5658
Practice Address - Fax:901-684-1277
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL.P.C. 404101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional