Provider Demographics
NPI:1013138965
Name:BANTA, MARK CODY (LPC U/S, CADC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:CODY
Last Name:BANTA
Suffix:
Gender:M
Credentials:LPC U/S, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1216 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5788
Mailing Address - Country:US
Mailing Address - Phone:405-285-7605
Mailing Address - Fax:405-552-2611
Practice Address - Street 1:3033 N WALNUT AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2832
Practice Address - Country:US
Practice Address - Phone:405-230-1145
Practice Address - Fax:405-552-2611
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)