Provider Demographics
NPI:1205502119
Name:BANKS, CHARLES WESLEY III
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WESLEY
Last Name:BANKS
Suffix:III
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 1:731 BIELENBERG DR STE 102-104
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1700
Mailing Address - Country:US
Mailing Address - Phone:612-800-8344
Mailing Address - Fax:612-445-8325
Practice Address - Street 1:731 BIELENBERG DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1700
Practice Address - Country:US
Practice Address - Phone:612-800-8344
Practice Address - Fax:612-445-8325
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician