Provider Demographics
NPI:1013302264
Name:BANEVER, SETH
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:BANEVER
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 1:263 FARMINGTON AVE
Mailing Address - Street 2:UCONN SCHOOL OF MEDICINE, PSYCHIATRY, C/O TERRI CARRIER
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2103
Mailing Address - Country:US
Mailing Address - Phone:860-679-4733
Mailing Address - Fax:
Practice Address - Street 1:270 FARMINGTON AVE STE 309
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1953
Practice Address - Country:US
Practice Address - Phone:860-677-5570
Practice Address - Fax:860-677-9570
Is Sole Proprietor?:No
Enumeration Date:2015-04-04
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT6299212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1013302264Medicaid