Provider Demographics
NPI:1013524008
Name:BANUA, KRISTEN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BANUA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1030 LOFTIS BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2999
Mailing Address - Country:US
Mailing Address - Phone:757-720-0099
Mailing Address - Fax:757-383-7898
Practice Address - Street 1:1030 LOFTIS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2999
Practice Address - Country:US
Practice Address - Phone:757-720-0099
Practice Address - Fax:757-383-7898
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133003778103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1-20-44556OtherBCBA