Provider Demographics
NPI:1437568797
Name:BANKS, TRAVIS (CADC L)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BANKS
Suffix:
Gender:M
Credentials:CADC L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 W HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-1490
Mailing Address - Country:US
Mailing Address - Phone:559-788-1500
Mailing Address - Fax:
Practice Address - Street 1:1055 W HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1490
Practice Address - Country:US
Practice Address - Phone:559-788-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI22110919101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI-B1301041335OtherAOD REGISTRATION NUMBER