Provider Demographics
NPI:1225790694
Name:BANTHER, MELISSA JEAN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:BANTHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:MART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4799
Mailing Address - Country:US
Mailing Address - Phone:800-438-1772
Mailing Address - Fax:262-345-5562
Practice Address - Street 1:2720 SUPERIOR DR NW STE 103
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1775
Practice Address - Country:US
Practice Address - Phone:004-381-7728
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician