Provider Demographics
NPI:1861539546
Name:BANNER, MATTHEW RAY IV (MA, LPC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RAY
Last Name:BANNER
Suffix:IV
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2546 SWEETWATER CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-9382
Mailing Address - Country:US
Mailing Address - Phone:303-842-8206
Mailing Address - Fax:
Practice Address - Street 1:732 FRONT ST
Practice Address - Street 2:STE. 202
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1863
Practice Address - Country:US
Practice Address - Phone:720-563-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health