Provider Demographics
NPI:1639632722
Name:BANKHEAD, ANEESAH MAILAKIA (TCADC)
Entity Type:Individual
Prefix:
First Name:ANEESAH
Middle Name:MAILAKIA
Last Name:BANKHEAD
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3369
Mailing Address - Country:US
Mailing Address - Phone:859-444-4499
Mailing Address - Fax:
Practice Address - Street 1:1450 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3369
Practice Address - Country:US
Practice Address - Phone:859-444-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170644101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2405Medicaid