Provider Demographics
NPI:1821732223
Name:BANACH, IVY J
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:J
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 1:175 MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-5635
Mailing Address - Country:US
Mailing Address - Phone:845-702-6810
Mailing Address - Fax:
Practice Address - Street 1:175 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-5635
Practice Address - Country:US
Practice Address - Phone:845-702-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059270-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY059270-01OtherSTATE OF NEW YORK EDUCATION DEPARTMENT