Provider Demographics
NPI:1003591769
Name:BANTA, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BANTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 CONCART ST
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-4213
Mailing Address - Country:US
Mailing Address - Phone:504-701-4709
Mailing Address - Fax:
Practice Address - Street 1:4805 W 4TH ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1019
Practice Address - Country:US
Practice Address - Phone:601-270-6968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist