Provider Demographics
NPI:1154964757
Name:BANKS, SHADONNA ROSHAWN (LADAC 1)
Entity type:Individual
Prefix:
First Name:SHADONNA
Middle Name:ROSHAWN
Last Name:BANKS
Suffix:
Gender:F
Credentials:LADAC 1
Other - Prefix:
Other - First Name:SHADONNA
Other - Middle Name:ROSHAWN
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADAC 1
Mailing Address - Street 1:100 OAK VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-6021
Mailing Address - Country:US
Mailing Address - Phone:470-991-4088
Mailing Address - Fax:901-443-5089
Practice Address - Street 1:119 RACINE ST STE 105
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-2729
Practice Address - Country:US
Practice Address - Phone:470-991-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1619101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty