Provider Demographics
NPI:1336278118
Name:BANNISH, MELANIE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:
Last Name:BANNISH
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-4026
Mailing Address - Country:US
Mailing Address - Phone:314-229-6779
Mailing Address - Fax:314-229-6779
Practice Address - Street 1:3909A MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-4026
Practice Address - Country:US
Practice Address - Phone:314-229-6779
Practice Address - Fax:314-773-6073
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0026331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497945006Medicaid