Provider Demographics
NPI:1821462367
Name:BANKSTON, SHAY ELLETHA (LISW)
Entity Type:Individual
Prefix:
First Name:SHAY
Middle Name:ELLETHA
Last Name:BANKSTON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 ANGOLA ROAD LOT 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615
Mailing Address - Country:US
Mailing Address - Phone:419-290-6323
Mailing Address - Fax:
Practice Address - Street 1:5702 ANGOLA RD LOT 3
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-6339
Practice Address - Country:US
Practice Address - Phone:419-290-6323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.15023481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical