Healthcare Provider Details

I. General information

NPI: 1093660342
Provider Name (Legal Business Name): JOE BANNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W METROPOLITAN DR STE 405
ORANGE CA
92868-3504
US

IV. Provider business mailing address

4000 W METROPOLITAN DR STE 405
ORANGE CA
92868-3504
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-4337
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number94028052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: