Provider Demographics
NPI:1609000561
Name:BANTA, ROBERT E (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:BANTA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9160 S 300 W
Mailing Address - Street 2:SUITE 22
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2655
Mailing Address - Country:US
Mailing Address - Phone:801-716-0440
Mailing Address - Fax:801-208-1011
Practice Address - Street 1:9160 S 300 W
Practice Address - Street 2:SUITE 22
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2655
Practice Address - Country:US
Practice Address - Phone:801-716-0440
Practice Address - Fax:801-208-1011
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT362807-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical