Provider Demographics
NPI:1346412780
Name:BANTA, ELAINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:BANTA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NA1A
Mailing Address - Street 2:STE B106
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477
Mailing Address - Country:US
Mailing Address - Phone:561-427-0144
Mailing Address - Fax:561-747-0258
Practice Address - Street 1:725 NA1A
Practice Address - Street 2:STE B106
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477
Practice Address - Country:US
Practice Address - Phone:561-427-0144
Practice Address - Fax:561-747-0258
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4354103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical