Healthcare Provider Details

I. General information

NPI: 1861547218
Provider Name (Legal Business Name): KEITH BANTA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 NEWBURG RD SUITE 212
LOUISVILLE KY
40218-2497
US

IV. Provider business mailing address

3430 NEWBURG RD SUITE 212
LOUISVILLE KY
40218-2497
US

V. Phone/Fax

Practice location:
  • Phone: 502-454-8800
  • Fax: 502-736-0140
Mailing address:
  • Phone: 502-454-8800
  • Fax: 502-736-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1194
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: