Provider Demographics
NPI:1831353911
Name:BANTON, LYDIA RUTH (LMHC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:RUTH
Last Name:BANTON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7561
Mailing Address - Fax:317-355-6096
Practice Address - Street 1:5470 EAST 16TH STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4861
Practice Address - Country:US
Practice Address - Phone:317-355-5394
Practice Address - Fax:317-351-7580
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002262A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530Medicaid
IN100270530Medicaid