Provider Demographics
NPI:1558816264
Name:BANKS WIMBLEY, BREA (PHDM LP)
Entity Type:Individual
Prefix:DR
First Name:BREA
Middle Name:
Last Name:BANKS WIMBLEY
Suffix:
Gender:F
Credentials:PHDM LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COLORADO STATE UNIVERSITY
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80523-0001
Mailing Address - Country:US
Mailing Address - Phone:970-491-7494
Mailing Address - Fax:
Practice Address - Street 1:COLORADO STATE UNIVERSITY
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-0001
Practice Address - Country:US
Practice Address - Phone:970-491-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY: 0004457103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical