Basic Information
| Provider Information | |||||||||
| NPI: | 1689047946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | PABLO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 W METROPOLITAN DR # 405 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146458000 | ||||||||
| FaxNumber: | 7149542985 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 W METROPOLITAN DR # 405 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146458000 | ||||||||
| FaxNumber: | 7149542985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2015 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 131602 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.