Provider Demographics
NPI:1962725408
Name:BANTA, MARLYNN (MFT)
Entity type:Individual
Prefix:MRS
First Name:MARLYNN
Middle Name:
Last Name:BANTA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1885
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0599
Mailing Address - Country:US
Mailing Address - Phone:909-253-3490
Mailing Address - Fax:
Practice Address - Street 1:101 E REDLANDS BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4775
Practice Address - Country:US
Practice Address - Phone:909-289-4075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39401106H00000X
CARN486960163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163W00000XNursing Service ProvidersRegistered Nurse