Provider Demographics
NPI:1356369854
Name:BANKS, GERALDINE B (PH D)
Entity type:Individual
Prefix:
First Name:GERALDINE
Middle Name:B
Last Name:BANKS
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4503
Mailing Address - Country:US
Mailing Address - Phone:414-962-4048
Mailing Address - Fax:414-962-4052
Practice Address - Street 1:5900 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4503
Practice Address - Country:US
Practice Address - Phone:414-962-4048
Practice Address - Fax:414-962-4052
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1543 057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39112400Medicaid
WI39112400Medicaid