Provider Demographics
NPI:1225610298
Name:BANKS, BRETT WILLIAM JR
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:WILLIAM
Last Name:BANKS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-3015
Mailing Address - Country:US
Mailing Address - Phone:937-716-1791
Mailing Address - Fax:
Practice Address - Street 1:1322 EPWORTH AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-2616
Practice Address - Country:US
Practice Address - Phone:937-479-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OHSM251752171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor