Provider Demographics
NPI:1720462740
Name:BANAS, KELLY NOELLE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NOELLE
Last Name:BANAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NOELLE
Other - Last Name:STOCKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2647
Mailing Address - Street 2:
Mailing Address - City:CRESTED BUTTE
Mailing Address - State:CO
Mailing Address - Zip Code:81224-2647
Mailing Address - Country:US
Mailing Address - Phone:610-547-6674
Mailing Address - Fax:
Practice Address - Street 1:123 W TOMICHI AVE STE 8
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2345
Practice Address - Country:US
Practice Address - Phone:719-838-3912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0105367101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health