Provider Demographics
NPI:1285623041
Name:BANKS, SARJAN B (SLP)
Entity type:Individual
Prefix:
First Name:SARJAN
Middle Name:B
Last Name:BANKS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:BERGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35 PICKWICK RD
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-2937
Mailing Address - Country:US
Mailing Address - Phone:203-435-1921
Mailing Address - Fax:
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014831231H00000X
CT003986235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00140796Medicaid
NYB82629Medicare ID - Type Unspecified
NYB82629Medicare UPIN