Provider Demographics
NPI:1073071510
Name:BANAAG, NATHAN
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:BANAAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6629
Mailing Address - Country:US
Mailing Address - Phone:408-506-3736
Mailing Address - Fax:
Practice Address - Street 1:18008 SKY PARK CIR STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6434
Practice Address - Country:US
Practice Address - Phone:949-474-1493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-80164106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician