Provider Demographics
NPI:1386280352
Name:BANTA, TERRY DENISE (CSWA)
Entity type:Individual
Prefix:MS
First Name:TERRY
Middle Name:DENISE
Last Name:BANTA
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8332
Mailing Address - Country:US
Mailing Address - Phone:623-866-9360
Mailing Address - Fax:
Practice Address - Street 1:2460 4TH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8332
Practice Address - Country:US
Practice Address - Phone:623-866-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA42551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical