Provider Demographics
NPI:1669280616
Name:BANKS, OLIVIA LARREN
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LARREN
Last Name:BANKS
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 1:5776 GRAPE RD
Mailing Address - Street 2:PMB 171
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8460
Mailing Address - Country:US
Mailing Address - Phone:574-217-1624
Mailing Address - Fax:
Practice Address - Street 1:4609 GRAPE RD STE D1B
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-8259
Practice Address - Country:US
Practice Address - Phone:574-217-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN21-168334106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician