Provider Demographics
NPI:1700459351
Name:BANNER, REED
Entity type:Individual
Prefix:
First Name:REED
Middle Name:
Last Name:BANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 ROMAIN RD
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-9302
Mailing Address - Country:US
Mailing Address - Phone:586-746-7445
Mailing Address - Fax:
Practice Address - Street 1:1300 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4732
Practice Address - Country:US
Practice Address - Phone:989-401-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
NV1689233579261QC1500X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health