Provider Demographics
NPI:1912127879
Name:BANNISTER, MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UTA HEALTH SERVICES
Mailing Address - Street 2:BOX 19329
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76019-0329
Mailing Address - Country:US
Mailing Address - Phone:817-272-2771
Mailing Address - Fax:817-272-2744
Practice Address - Street 1:UTA HEALTH SERVICES
Practice Address - Street 2:605 S. WEST STREET
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76019-0329
Practice Address - Country:US
Practice Address - Phone:817-272-2771
Practice Address - Fax:817-272-2744
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25625103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical