MEDICARE: DR. CARYN MARGARET BANQUE PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY24416	CA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	H0501251418	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY24416	OTHER	CA	CA STATE LICENSE

General Provider Information

NPI Number	:	1477685253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARYN MARGARET BANQUE PSYD

Provider Business Mailing Address
First Line	:	PO BOX 65
Second Line	:
City	:	WEIMAR
State	:	CA
Zip	:	95736-0065
Country	:	US
Telephone Number	:	530-383-3051
Fax Number	:

Provider Business Practice Location Address
First Line	:	2621 CAPITOL AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-5920
Country	:	US
Telephone Number	:	530-383-3051
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	11/15/2023

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