Provider Demographics
NPI:1598330177
Name:BANNER, KLEM
Entity Type:Individual
Prefix:
First Name:KLEM
Middle Name:
Last Name:BANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 N TUSTIN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3731
Mailing Address - Country:US
Mailing Address - Phone:949-701-2740
Mailing Address - Fax:949-606-7089
Practice Address - Street 1:640 N TUSTIN AVE STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3731
Practice Address - Country:US
Practice Address - Phone:949-701-2740
Practice Address - Fax:949-606-7089
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician