Provider Demographics
NPI:1225790694
Name:BANTHER, MELISSA JEAN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:JEAN
Last Name:BANTHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JEAN
Other - Last Name:MART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10084 E STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:47424-6063
Mailing Address - Country:US
Mailing Address - Phone:507-703-3512
Mailing Address - Fax:
Practice Address - Street 1:10084 E STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IN
Practice Address - Zip Code:47424-6063
Practice Address - Country:US
Practice Address - Phone:507-703-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4573106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist