Provider Demographics
NPI:1720577141
Name:BANKS, AUSTIN R JR (SPORTS MANAGEMENT)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:R
Last Name:BANKS
Suffix:JR
Gender:M
Credentials:SPORTS MANAGEMENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 GLADIOLA CT
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-2429
Mailing Address - Country:US
Mailing Address - Phone:504-799-9207
Mailing Address - Fax:
Practice Address - Street 1:14 GLADIOLA CT
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-2429
Practice Address - Country:US
Practice Address - Phone:985-956-7650
Practice Address - Fax:985-956-7561
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1255681128Medicaid