Basic Information
| Provider Information | |||||||||
| NPI: | 1770158784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANGO | ||||||||
| FirstName: | AUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2191 MEMORIAL DR APT B16 | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370434407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9809259363 | ||||||||
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| Practice Location | |||||||||
| Address1: | 511 8TH ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370403093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9319207200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2021 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.