Provider Demographics
NPI:1619414364
Name:BANNERT, KURT (LPC)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:BANNERT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E MARSHALL AVE
Mailing Address - Street 2:SUITE #310
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5659
Mailing Address - Country:US
Mailing Address - Phone:903-431-2599
Mailing Address - Fax:
Practice Address - Street 1:701 E MARSHALL AVE
Practice Address - Street 2:SUITE #310
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5659
Practice Address - Country:US
Practice Address - Phone:903-431-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74055101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional