Healthcare Provider Details

I. General information

NPI: 1437336104
Provider Name (Legal Business Name): RONALD HARLAN BANNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 REDONDO AVE
LONG BEACH CA
90804-3928
US

IV. Provider business mailing address

1041 REDONDO AVE
LONG BEACH CA
90804-3928
US

V. Phone/Fax

Practice location:
  • Phone: 562-715-5801
  • Fax: 562-987-4586
Mailing address:
  • Phone: 562-715-5801
  • Fax: 562-987-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY3399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: