Provider Demographics
NPI:1528804523
Name:BANTA, THOMAS PATRICK
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:PATRICK
Last Name:BANTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:BANTA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAC
Mailing Address - Street 1:202 TYNE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3444
Mailing Address - Country:US
Mailing Address - Phone:859-640-0623
Mailing Address - Fax:
Practice Address - Street 1:202 TYNE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3444
Practice Address - Country:US
Practice Address - Phone:859-640-0623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001398A101YM0800X
IN87001744A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health