Healthcare Provider Details

I. General information

NPI: 1780016832
Provider Name (Legal Business Name): GREG BANKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 BROADWAY
OAKLAND CA
94612
US

IV. Provider business mailing address

3708 GRAND AVE
OAKLAND CA
94610
US

V. Phone/Fax

Practice location:
  • Phone: 510-628-9065
  • Fax:
Mailing address:
  • Phone: 831-359-9097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: