Basic Information
| Provider Information | |||||||||
| NPI: | 1487907606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANTHER | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3872 ASH AVE SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973024703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066501543 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1233 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033787526 | ||||||||
| FaxNumber: | 5034801630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2012 | ||||||||
| LastUpdateDate: | 07/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L7065 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.