Provider Demographics
NPI:1891210910
Name:BANKS, EDDIE L JR
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:L
Last Name:BANKS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 SILKWOOD CIR
Mailing Address - Street 2:927
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-3381
Mailing Address - Country:US
Mailing Address - Phone:407-580-3872
Mailing Address - Fax:
Practice Address - Street 1:2724 SILKWOOD CIR.
Practice Address - Street 2:927
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818
Practice Address - Country:US
Practice Address - Phone:407-580-3872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X, 171W00000X, 252Y00000X, 390200000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No171W00000XOther Service ProvidersContractor
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty