Provider Demographics
NPI:1417592072
Name:BANTA, KERRY DAVENPORT (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:DAVENPORT
Last Name:BANTA
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 N 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2904
Mailing Address - Country:US
Mailing Address - Phone:717-503-5909
Mailing Address - Fax:
Practice Address - Street 1:218 N 29TH ST
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2904
Practice Address - Country:US
Practice Address - Phone:717-503-5909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011943101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional