Healthcare Provider Details

I. General information

NPI: 1710430137
Provider Name (Legal Business Name): BRIAN BANTEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9375 E SHEA BLVD STE 100
SCOTTSDALE AZ
85260-6986
US

IV. Provider business mailing address

9375 E SHEA BLVD STE 100
SCOTTSDALE AZ
85260-6986
US

V. Phone/Fax

Practice location:
  • Phone: 480-992-4996
  • Fax: 480-878-3770
Mailing address:
  • Phone: 480-992-4996
  • Fax: 480-878-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005364
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY-005364
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPSY-005364
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY-005364
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: