Provider Demographics
NPI:1629150222
Name:BANKS, SHARON KAY (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:KAY
Last Name:BANKS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:SHARON
Other - Middle Name:KAY
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MS
Mailing Address - Zip Code:39175-0091
Mailing Address - Country:US
Mailing Address - Phone:601-624-2043
Mailing Address - Fax:601-885-2060
Practice Address - Street 1:1308 BARLOW DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MS
Practice Address - Zip Code:39175-9423
Practice Address - Country:US
Practice Address - Phone:601-624-2043
Practice Address - Fax:601-885-2060
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT 0346225X00000X
MSOT0346261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118814Medicaid