Provider Demographics
NPI:1508345158
Name:BANKS, BRIDGETTE IDETTE (MAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:IDETTE
Last Name:BANKS
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HICKORY KNOLL DR APT 401
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2444
Mailing Address - Country:US
Mailing Address - Phone:616-773-9018
Mailing Address - Fax:
Practice Address - Street 1:111 HICKORY KNOLL DR APT 401
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2444
Practice Address - Country:US
Practice Address - Phone:616-773-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0032862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer