Provider Demographics
NPI:1013517465
Name:BANKS, TEQUILA OLIVIA (LPC)
Entity Type:Individual
Prefix:
First Name:TEQUILA
Middle Name:OLIVIA
Last Name:BANKS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8303 DUNLEAF ARC WAY NW
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093
Mailing Address - Country:US
Mailing Address - Phone:470-658-8156
Mailing Address - Fax:
Practice Address - Street 1:8303 DUNLEAF ARC WAY NW
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093
Practice Address - Country:US
Practice Address - Phone:470-658-8156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC0011830101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional