Healthcare Provider Details

I. General information

NPI: 1710824537
Provider Name (Legal Business Name): EMMANUEL ENOCH BANTO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 W DUNLAP AVE STE D
PHOENIX AZ
85051-5300
US

IV. Provider business mailing address

3612 W DUNLAP AVE STE D
PHOENIX AZ
85051-5300
US

V. Phone/Fax

Practice location:
  • Phone: 774-242-9221
  • Fax: 999-999-9999
Mailing address:
  • Phone: 774-242-9221
  • Fax: 999-999-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: