Provider Demographics
NPI:1588045827
Name:BANKS, CRYSTAL (MS TLLP)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:MS TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28303 JOY RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-5524
Mailing Address - Country:US
Mailing Address - Phone:734-513-1122
Mailing Address - Fax:
Practice Address - Street 1:28303 JOY RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-5524
Practice Address - Country:US
Practice Address - Phone:734-513-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016295103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical