Healthcare Provider Details

I. General information

NPI: 1225233034
Provider Name (Legal Business Name): MARY PATRICE BANTON M.ED., LPC, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAT BANTON M.ED, LPC, LCSW

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N GORE AVE
WEBSTER GROVES MO
63119-1600
US

IV. Provider business mailing address

809 GUENEVERE DR
BALLWIN MO
63011-3526
US

V. Phone/Fax

Practice location:
  • Phone: 314-619-4729
  • Fax: 314-919-4850
Mailing address:
  • Phone: 314-619-4729
  • Fax: 314-919-4850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002431
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001291
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: