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General NPI Number Information
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NPI Number | 1457219842
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Entity Type | Individual
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Provider Name | MATT BANNISTER
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Gender | Male
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Dates
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Enumeration Date | 01/13/2026
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Last Update Date | 01/13/2026
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Provider Practice Location Address
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Address Line | 206 E ELM ST
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City | CALDWELL
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State | ID
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Zip | 83605-4815
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Country | US
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Telephone | 208-454-8389
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Fax | 951-264-6365
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Provider Business Mailing Address
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Address Line | 1810 TAFT ST
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City | CALDWELL
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State | ID
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Zip | 83605-2156
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Country | US
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Telephone | 951-264-6365
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Fax | 951-264-6365
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041S0200X
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Taxonomy Name | School Social Worker
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License Number | 2371596
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License Number State | ID
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