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General NPI Number Information
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NPI Number | 1992198543
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Entity Type | Organization
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Legal Business Name | BANYAN GROUP
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Dates
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Enumeration Date | 03/06/2015
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Last Update Date | 04/06/2015
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Provider Practice Location Address
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Address Line | 372 E 7TH ST
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City | BEAUMONT
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State | CA
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Zip | 92223-2261
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Country | US
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Telephone | 951-845-4073
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Fax | 201-353-8530
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Provider Business Mailing Address
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Address Line | 372 E 7TH ST
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City | BEAUMONT
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State | CA
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Zip | 92223-2261
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Country | US
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Telephone | 951-845-4073
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Fax | 201-353-8530
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Authorized Official
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Title or Position | PRESIDENT; DIRECTOR OF COUNSELING
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Name | MRS. DANECE RENEE STAPLETON
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Credential | LCSW
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Telephone | 951-845-4073
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 64658
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License Number State | CA
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