Provider Demographics
NPI:1710360847
Name:BANKSTON, GABRIELLE (LMT)
Entity Type:Individual
Prefix:MISS
First Name:GABRIELLE
Middle Name:
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 JONESVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:YEMASSEE
Mailing Address - State:SC
Mailing Address - Zip Code:29945-4703
Mailing Address - Country:US
Mailing Address - Phone:843-214-8646
Mailing Address - Fax:
Practice Address - Street 1:191 JONESVILLE AVE
Practice Address - Street 2:
Practice Address - City:YEMASSEE
Practice Address - State:SC
Practice Address - Zip Code:29945-4703
Practice Address - Country:US
Practice Address - Phone:843-214-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist