Provider Demographics
NPI:1467789768
Name:BANTA, LAUREL ANN (M A, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:ANN
Last Name:BANTA
Suffix:
Gender:F
Credentials:M A, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 LIVE OAK BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-4028
Mailing Address - Country:US
Mailing Address - Phone:530-673-2100
Mailing Address - Fax:530-674-2414
Practice Address - Street 1:1002 LIVE OAK BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-4028
Practice Address - Country:US
Practice Address - Phone:530-673-2100
Practice Address - Fax:530-674-2414
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist