Provider Demographics
NPI:1134519523
Name:BANIEWICZ, MICHAEL (PSYD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BANIEWICZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W 8TH AVE STE I
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W 8TH AVE STE I
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-1349
Practice Address - Country:US
Practice Address - Phone:856-346-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005164101YP2500X
PAPS018515103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional