Provider Demographics
NPI:1417396078
Name:BANKS, HEATHER LEE (CDP)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:LEE
Last Name:BANKS
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17018 15TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5126
Mailing Address - Country:US
Mailing Address - Phone:425-408-7868
Mailing Address - Fax:
Practice Address - Street 1:17018 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-5126
Practice Address - Country:US
Practice Address - Phone:425-408-7868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60275845101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP 60275845OtherCDP