Provider Demographics
NPI:1730859539
Name:BANACH, KIMBERLY ELLEN
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ELLEN
Last Name:BANACH
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 1:75 BOND RD
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-1301
Mailing Address - Country:US
Mailing Address - Phone:774-200-3942
Mailing Address - Fax:
Practice Address - Street 1:75 BOND RD
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507-1301
Practice Address - Country:US
Practice Address - Phone:508-523-8371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health