Provider Demographics
NPI:1770738841
Name:BANKS, TYRA M (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TYRA
Middle Name:M
Last Name:BANKS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 MILBURN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-5158
Mailing Address - Country:US
Mailing Address - Phone:516-860-9677
Mailing Address - Fax:
Practice Address - Street 1:3512 MILBURN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510
Practice Address - Country:US
Practice Address - Phone:516-860-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00478900171W00000X
NY011886-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor