MEDICARE: MS. CARLA D. BANKS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1597-123	WI

General Provider Information

NPI Number	:	1003065954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CARLA D. BANKS LCSW

Provider Business Mailing Address
First Line	:	5886 BARKELEY AVE
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4152
Country	:	US
Telephone Number	:	719-526-9730
Fax Number	:

Provider Business Practice Location Address
First Line	:	5886 BARKELEY AVE
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4152
Country	:	US
Telephone Number	:	719-526-9730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	09/16/2008

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