Provider Demographics
NPI:1548094311
Name:LAGUATAN, BANIBAJA CLHAVINZKY SILALAHI
Entity type:Individual
Prefix:
First Name:BANIBAJA
Middle Name:CLHAVINZKY SILALAHI
Last Name:LAGUATAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BANIBAJA
Other - Middle Name:CLHAVINZKY THERESIA
Other - Last Name:SILALAHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:328 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-4653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1711 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-9320
Practice Address - Country:US
Practice Address - Phone:843-460-2605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-22-217639106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician