Provider Demographics
NPI:1407404213
Name:BANKSTON, ALLISON (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 LAKE GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:SEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32190-7906
Mailing Address - Country:US
Mailing Address - Phone:386-307-8782
Mailing Address - Fax:
Practice Address - Street 1:115 E HOWRY AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-5516
Practice Address - Country:US
Practice Address - Phone:386-307-8782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17232101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health