Provider Demographics
NPI:1134802259
Name:BANISTER, LEON JR
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:
Last Name:BANISTER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 TIGERTAIL CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4724
Mailing Address - Country:US
Mailing Address - Phone:786-566-2875
Mailing Address - Fax:
Practice Address - Street 1:2310 TIGERTAIL CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4724
Practice Address - Country:US
Practice Address - Phone:786-566-2875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14204101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health