Basic Information
| Provider Information | |||||||||
| NPI: | 1952694507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RABANERA | ||||||||
| FirstName: | CHRIS NEIL | ||||||||
| MiddleName: | RENDON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RABANERA | ||||||||
| OtherFirstName: | CHRIS | ||||||||
| OtherMiddleName: | RENDON | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 75 BUSCHLEN RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | BAD AXE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484139177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896239300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75 BUSCHLEN RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | BAD AXE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484139177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896239300 | ||||||||
| FaxNumber: | 7607889754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2011 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 63843 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4101006876 | 01 | MI | STATE LICENSE | OTHER |