Healthcare Provider Details

I. General information

NPI: 1033258801
Provider Name (Legal Business Name): MRS. LYDIA ANN BANKS I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 S WESTERN AVE
LOS ANGELES CA
90062-1105
US

IV. Provider business mailing address

3701 W 27TH ST
LOS ANGELES CA
90018-2309
US

V. Phone/Fax

Practice location:
  • Phone: 323-290-4354
  • Fax: 323-293-3327
Mailing address:
  • Phone: 323-804-1435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: