Healthcare Provider Details

I. General information

NPI: 1164545877
Provider Name (Legal Business Name): CHRISTOPHER JOSEPH BANTA BA PSYCHOLOGY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 DIVIDEND DR STE 3
REXBURG ID
83440-3510
US

IV. Provider business mailing address

635 ANGELA DR
REXBURG ID
83440-1422
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-9683
  • Fax:
Mailing address:
  • Phone: 208-351-0149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: