Provider Demographics
NPI:1699112680
Name:BANKS, LARRY (LBSW QMHP)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:BANKS
Suffix:
Gender:M
Credentials:LBSW QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 VANCE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6449
Mailing Address - Country:US
Mailing Address - Phone:989-430-2177
Mailing Address - Fax:
Practice Address - Street 1:218 FAST ICE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6167
Practice Address - Country:US
Practice Address - Phone:989-631-5140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085837104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker