Provider Demographics
NPI:1235606096
Name:BANKSTON, SUZANNE BONNETTE
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:BONNETTE
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HEBERT ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-5916
Mailing Address - Country:US
Mailing Address - Phone:225-405-0749
Mailing Address - Fax:
Practice Address - Street 1:333 LEE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4980
Practice Address - Country:US
Practice Address - Phone:225-215-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.Z11543225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist