Healthcare Provider Details

I. General information

NPI: 1053580381
Provider Name (Legal Business Name): GLENN L BANKS JR. LIAC, MFCT, CCTP-II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3591 S MERCY RD STE 204
GILBERT AZ
85297-2240
US

IV. Provider business mailing address

1455 N GAYLORD CIR
MESA AZ
85213-4120
US

V. Phone/Fax

Practice location:
  • Phone: 623-241-8787
  • Fax:
Mailing address:
  • Phone: 480-203-5501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10525
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberLISAC-10525
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: