Provider Demographics
NPI:1811746324
Name:BANTON, ZASHUAN
Entity type:Individual
Prefix:
First Name:ZASHUAN
Middle Name:
Last Name:BANTON
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 1:1290 SW PATRICIA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5007
Mailing Address - Country:US
Mailing Address - Phone:754-265-2945
Mailing Address - Fax:
Practice Address - Street 1:1401 SE GOLDTREE DR STE 101
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7584
Practice Address - Country:US
Practice Address - Phone:772-212-7539
Practice Address - Fax:772-673-8392
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-339383106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician