Provider Demographics
NPI:1447859970
Name:BANTHER, KELLI RUTH
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:RUTH
Last Name:BANTHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 AMNICOLA HWY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-3605
Mailing Address - Country:US
Mailing Address - Phone:833-825-5246
Mailing Address - Fax:877-866-6152
Practice Address - Street 1:2826 AMNICOLA HWY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-3605
Practice Address - Country:US
Practice Address - Phone:833-825-5246
Practice Address - Fax:877-866-6152
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician