Provider Demographics
NPI:1972260735
Name:NGO BANACK, ADELE MARIE
Entity Type:Individual
Prefix:
First Name:ADELE
Middle Name:MARIE
Last Name:NGO BANACK
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 1:1755 N BROWN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-2018
Mailing Address - Country:US
Mailing Address - Phone:678-851-9972
Mailing Address - Fax:
Practice Address - Street 1:1755 N BROWN RD STE 200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-2018
Practice Address - Country:US
Practice Address - Phone:678-851-9972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT006744225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist