Healthcare Provider Details

I. General information

NPI: 1013138965
Provider Name (Legal Business Name): MARK CODY BANTA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105365 S.HWY 102
MCLOUD OK
74851
US

IV. Provider business mailing address

43925 HUNTERS HILL DR
SHAWNEE OK
74801-8927
US

V. Phone/Fax

Practice location:
  • Phone: 405-988-2618
  • Fax:
Mailing address:
  • Phone: 405-988-2075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number04525
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: