Provider Demographics
NPI:1891107421
Name:BANKS, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 CLEVELAND AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1218
Mailing Address - Country:US
Mailing Address - Phone:763-913-8261
Mailing Address - Fax:
Practice Address - Street 1:670 CLEVELAND AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1218
Practice Address - Country:US
Practice Address - Phone:763-913-8261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2450106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist