Provider Demographics
NPI:1760809677
Name:BANKS, LAEARTHA ISHSTARA (LPC)
Entity Type:Individual
Prefix:
First Name:LAEARTHA
Middle Name:ISHSTARA
Last Name:BANKS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7524 GLENN HILLS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-7870
Mailing Address - Country:US
Mailing Address - Phone:501-993-6044
Mailing Address - Fax:
Practice Address - Street 1:500 S ROSSER ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-3742
Practice Address - Country:US
Practice Address - Phone:501-993-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1701216101YP2500X, 101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138580726Medicaid