Provider Demographics
NPI:1225233034
Name:BANTON, MARY PATRICE (MED, LPC, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:PATRICE
Last Name:BANTON
Suffix:
Gender:F
Credentials:MED, LPC, LCSW
Other - Prefix:
Other - First Name:PAT
Other - Middle Name:
Other - Last Name:BANTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, LPC, LCSW
Mailing Address - Street 1:809 GUENEVERE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3526
Mailing Address - Country:US
Mailing Address - Phone:314-619-4729
Mailing Address - Fax:314-919-4850
Practice Address - Street 1:330 N GORE AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-1600
Practice Address - Country:US
Practice Address - Phone:314-619-4729
Practice Address - Fax:314-919-4850
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0024311041C0700X
MO001291101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical