Provider Demographics
NPI:1306405774
Name:BANKER, KEITH MERWIN JR (MHRS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MERWIN
Last Name:BANKER
Suffix:JR
Gender:M
Credentials:MHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24077 STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-8519
Mailing Address - Country:US
Mailing Address - Phone:530-265-9057
Mailing Address - Fax:
Practice Address - Street 1:24077 STATE HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-8519
Practice Address - Country:US
Practice Address - Phone:530-265-9057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 101YM0800X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101Y00000XOtherCOUNSELOR