Basic Information
| Provider Information | |||||||||
| NPI: | 1356369854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANKS | ||||||||
| FirstName: | GERALDINE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532174503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149624048 | ||||||||
| FaxNumber: | 4149624052 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 N PORT WASHINGTON RD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | GLENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532174503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149624048 | ||||||||
| FaxNumber: | 4149624052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1543 057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 39112400 | 05 | WI | MEDICAID |