Provider Demographics
NPI:1275786386
Name:BANKS, SANDRA (PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 GRACELAND BLVD UNIT 204
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1887
Mailing Address - Country:US
Mailing Address - Phone:614-586-6573
Mailing Address - Fax:877-978-1246
Practice Address - Street 1:1161 BETHEL RD STE 104-1
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2773
Practice Address - Country:US
Practice Address - Phone:614-586-6573
Practice Address - Fax:877-978-1246
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016487103T00000X
OH7432103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0211098Medicaid
PA102219570 0002Medicaid
PA102317392 0001Medicaid