Provider Demographics
NPI:1790910669
Name:PULIDO-BANNER, MARY ANGELA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANGELA
Last Name:PULIDO-BANNER
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 1:6700 N LINDER RD STE 156A
Mailing Address - Street 2:#331
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6606
Mailing Address - Country:US
Mailing Address - Phone:775-781-3122
Mailing Address - Fax:775-319-5922
Practice Address - Street 1:1462 US HIGHWAY 395 N
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5203
Practice Address - Country:US
Practice Address - Phone:775-553-0668
Practice Address - Fax:775-319-5922
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY0951103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical