Provider Demographics
NPI:1689086985
Name:BANKS, CORDELIA (PTA)
Entity Type:Individual
Prefix:MS
First Name:CORDELIA
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2903
Mailing Address - Country:US
Mailing Address - Phone:973-743-3270
Mailing Address - Fax:
Practice Address - Street 1:497 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2903
Practice Address - Country:US
Practice Address - Phone:973-743-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00267000225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant