Provider Demographics
NPI:1336848225
Name:BANASIK, SANDRA MAGDALENA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MAGDALENA
Last Name:BANASIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11268 VISTA SORRENTO PKWY APT 205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-7635
Mailing Address - Country:US
Mailing Address - Phone:760-415-1522
Mailing Address - Fax:
Practice Address - Street 1:1550 HOTEL CIR N STE 450
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2933
Practice Address - Country:US
Practice Address - Phone:619-814-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-22-239026106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician