Healthcare Provider Details

I. General information

NPI: 1629494893
Provider Name (Legal Business Name): QUE'MESHA BANNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 21ST ST
BAKERSFIELD CA
93301-4709
US

IV. Provider business mailing address

1018 21ST ST
BAKERSFIELD CA
93301-4709
US

V. Phone/Fax

Practice location:
  • Phone: 661-861-9967
  • Fax: 661-861-0339
Mailing address:
  • Phone: 661-861-9967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: