Provider Demographics
NPI:1265577449
Name:BANIA, MAGGIE ELIZABETH (LP)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:ELIZABETH
Last Name:BANIA
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21617 NYSTROM LN
Mailing Address - Street 2:
Mailing Address - City:CORCORAN
Mailing Address - State:MN
Mailing Address - Zip Code:55340-9718
Mailing Address - Country:US
Mailing Address - Phone:763-478-4658
Mailing Address - Fax:
Practice Address - Street 1:7054 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1370
Practice Address - Country:US
Practice Address - Phone:763-560-9610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3330103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8H322BAOtherBCBS