Healthcare Provider Details

I. General information

NPI: 1477685253
Provider Name (Legal Business Name): CARYN MARGARET BANQUE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 CAPITOL AVE
SACRAMENTO CA
95816-5920
US

IV. Provider business mailing address

PO BOX 65
WEIMAR CA
95736-0065
US

V. Phone/Fax

Practice location:
  • Phone: 530-383-3051
  • Fax:
Mailing address:
  • Phone: 530-383-3051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberH0501251418
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY24416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: