Healthcare Provider Details

I. General information

NPI: 1801001789
Provider Name (Legal Business Name): JULIA LYNN BANTA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N WABASH AVE SUITE 2106
CHICAGO IL
60601-2406
US

IV. Provider business mailing address

1709 N PAULINA ST #103
CHICAGO IL
60622-1495
US

V. Phone/Fax

Practice location:
  • Phone: 312-551-9300
  • Fax:
Mailing address:
  • Phone: 773-384-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: