Provider Demographics
NPI:1194295832
Name:BANKHEAD, JOE MACK (DR)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:MACK
Last Name:BANKHEAD
Suffix:
Gender:M
Credentials:DR
Other - Prefix:DR
Other - First Name:JOE
Other - Middle Name:MACK
Other - Last Name:BVANKHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DR JOE MACK BANKHEAD
Mailing Address - Street 1:7199 BEAVER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SULLIGENT
Mailing Address - State:AL
Mailing Address - Zip Code:35586-4603
Mailing Address - Country:US
Mailing Address - Phone:205-698-0553
Mailing Address - Fax:
Practice Address - Street 1:7199 BEAVER CREEK RD
Practice Address - Street 2:
Practice Address - City:SULLIGENT
Practice Address - State:AL
Practice Address - Zip Code:35586-4603
Practice Address - Country:US
Practice Address - Phone:205-698-0553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20283101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL20283Medicaid