Individual
ALICIA BANISTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3930 SE IVON ST, PORTLAND, OR 97202-1651
(503) 893-2067
Mailing address
3930 SE IVON ST, PORTLAND, OR 97202-1651
(503) 893-2067
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
C6803
OR
225700000X
Massage Therapist
21093
OR
Other
Enumeration date
01/06/2015
Last updated
08/24/2023
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