Healthcare Provider Details

I. General information

NPI: 1245651181
Provider Name (Legal Business Name): KALEIGH BANTUM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2013
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 EMERYVILLE DR SUITE 230
CRANBERRY TOWNSHIP PA
16066-5020
US

IV. Provider business mailing address

125 EMERYVILLE DR SUITE 230
CRANBERRY TOWNSHIP PA
16066-5020
US

V. Phone/Fax

Practice location:
  • Phone: 724-609-5002
  • Fax:
Mailing address:
  • Phone: 724-609-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS018036
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: