Provider Demographics
NPI:1356069397
Name:BANASIK, MISTY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:BANASIK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25119 HAVERFORD RD
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-2942
Mailing Address - Country:US
Mailing Address - Phone:281-513-4404
Mailing Address - Fax:
Practice Address - Street 1:10255 MAHAFFEY RD
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-1442
Practice Address - Country:US
Practice Address - Phone:832-375-8279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113478235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist