| Doctor Name: | MR. CHRISTOPHER JOSEPH BANTA |
| NPI Number: | 1164545877 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | BA PSYCHOLOGY |
| License Number: | |
| Business Practice Address: | 218 Dividend Dr Ste 3 Rexburg, ID - 834403510 |
| Business Phone Number: | 2083599683 |
| Business Fax Number: | |
| Mailing Address: | 635 Angela Dr, REXBURG |
| State: | ID |
| Postal Code: | 834401422 |
| Phone Number: | 2083510149 |
| Fax Number: | |
| NPI Enumeration Date: | 04/09/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TR0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Rehabilitation |
| Taxonomy Definition: | |