Provider Demographics
NPI:1295580496
Name:BANKS, MIRA JEANINE (MSCJ)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:JEANINE
Last Name:BANKS
Suffix:
Gender:F
Credentials:MSCJ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1703
Mailing Address - Country:US
Mailing Address - Phone:419-841-7701
Mailing Address - Fax:
Practice Address - Street 1:2005 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43620-1703
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.187815101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)