Provider Demographics
NPI:1164545877
Name:BANTA, CHRISTOPHER JOSEPH (BA PSYCHOLOGY)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JOSEPH
Last Name:BANTA
Suffix:
Gender:M
Credentials:BA PSYCHOLOGY
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Mailing Address - Street 1:635 ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1422
Mailing Address - Country:US
Mailing Address - Phone:208-351-0149
Mailing Address - Fax:
Practice Address - Street 1:218 DIVIDEND DR STE 3
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3510
Practice Address - Country:US
Practice Address - Phone:208-359-9683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation