Healthcare Provider Details

I. General information

NPI: 1417814245
Provider Name (Legal Business Name): ROBERTA G BANNISTER CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23394 KNAPPS CUTOFF # 4387
CRESTLINE CA
92325-9427
US

IV. Provider business mailing address

PO BOX 4387
CRESTLINE CA
92325-4387
US

V. Phone/Fax

Practice location:
  • Phone: 840-210-1763
  • Fax:
Mailing address:
  • Phone: 840-210-1763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: