Provider Demographics
NPI:1295773232
Name:BANTZ, JODY
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:
Last Name:BANTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JODY
Other - Middle Name:LENORE
Other - Last Name:BANTZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 2253
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1085
Mailing Address - Country:US
Mailing Address - Phone:858-344-2668
Mailing Address - Fax:760-262-3026
Practice Address - Street 1:10455 POMERADO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131
Practice Address - Country:US
Practice Address - Phone:858-344-2668
Practice Address - Fax:760-262-3026
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20351103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL203510Medicare Oscar/Certification