Provider Demographics
NPI:1184785693
Name:BANICKI, GREGORY M (MS ED)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:M
Last Name:BANICKI
Suffix:
Gender:M
Credentials:MS ED
Other - Prefix:
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Mailing Address - Street 1:1910 SAINT JOE CENTER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5000
Mailing Address - Country:US
Mailing Address - Phone:260-484-5599
Mailing Address - Fax:260-484-5664
Practice Address - Street 1:1910 SAINT JOE CENTER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5000
Practice Address - Country:US
Practice Address - Phone:260-484-5599
Practice Address - Fax:260-484-5664
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health