Provider Demographics
NPI:1588936033
Name:BANTA, ROZALYNNE M (LPC)
Entity type:Individual
Prefix:
First Name:ROZALYNNE
Middle Name:M
Last Name:BANTA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N COLLEGE ST
Mailing Address - Street 2:P.O. BOX 627
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1912
Mailing Address - Country:US
Mailing Address - Phone:208-983-0235
Mailing Address - Fax:208-983-0245
Practice Address - Street 1:102 N COLLEGE ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1912
Practice Address - Country:US
Practice Address - Phone:208-983-0235
Practice Address - Fax:208-983-0245
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC4718101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor