Provider Demographics
NPI:1922206655
Name:BANASKY, NANCYBETH
Entity Type:Individual
Prefix:
First Name:NANCYBETH
Middle Name:
Last Name:BANASKY
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 1:13704 SE STEELE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4074
Mailing Address - Country:US
Mailing Address - Phone:503-762-3462
Mailing Address - Fax:
Practice Address - Street 1:5050 NE HOYT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2991
Practice Address - Country:US
Practice Address - Phone:503-215-6488
Practice Address - Fax:503-215-6485
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist