Provider Demographics
NPI:1164091641
Name:AGESA, BANNET (BA)
Entity type:Individual
Prefix:
First Name:BANNET
Middle Name:
Last Name:AGESA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 W BRIDGE ST # B5
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4342
Mailing Address - Country:US
Mailing Address - Phone:104-159-3016
Mailing Address - Fax:610-415-1656
Practice Address - Street 1:139 LEOPARD RD
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:PA
Practice Address - Zip Code:19312-1809
Practice Address - Country:US
Practice Address - Phone:215-839-8769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2025-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC018904101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional