Provider Demographics
NPI:1477685253
Name:BANQUE, CARYN MARGARET (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARYN
Middle Name:MARGARET
Last Name:BANQUE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:WEIMAR
Mailing Address - State:CA
Mailing Address - Zip Code:95736-0065
Mailing Address - Country:US
Mailing Address - Phone:530-383-3051
Mailing Address - Fax:
Practice Address - Street 1:2621 CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5920
Practice Address - Country:US
Practice Address - Phone:530-383-3051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24416103TC0700X
CAH0501251418101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY24416OtherCA STATE LICENSE