Provider Demographics
NPI:1164504601
Name:BANTON, RICHARD ALAN (DPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALAN
Last Name:BANTON
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12019 CANTER LN
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-2129
Mailing Address - Country:US
Mailing Address - Phone:703-967-8474
Mailing Address - Fax:
Practice Address - Street 1:12019 CANTER LN
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-2129
Practice Address - Country:US
Practice Address - Phone:703-967-8474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006492225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist