Provider Demographics
NPI:1922785351
Name:BANKS, LISANDRA JOSEPHINE HANNAH (PCLC)
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:JOSEPHINE HANNAH
Last Name:BANKS
Suffix:
Gender:F
Credentials:PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 GARLAND DR APT 10
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-2134
Mailing Address - Country:US
Mailing Address - Phone:765-623-2033
Mailing Address - Fax:
Practice Address - Street 1:1724 FAIRVIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7873
Practice Address - Country:US
Practice Address - Phone:406-214-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-63754101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health