Provider Demographics
NPI:1164208088
Name:BANAS, KRISTIN AMY (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:AMY
Last Name:BANAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:BANAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:617 VETERANS BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1404
Mailing Address - Country:US
Mailing Address - Phone:650-503-8179
Mailing Address - Fax:
Practice Address - Street 1:1010 GRAYSON ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2611
Practice Address - Country:US
Practice Address - Phone:650-503-8179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94027758103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist