Healthcare Provider Details

I. General information

NPI: 1972585255
Provider Name (Legal Business Name): CARY JAMES BANKA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3349 WILLOWCREEK RD
PORTAGE IN
46368-5015
US

IV. Provider business mailing address

8123 KOOY DR
MUNSTER IN
46321-1841
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-9557
  • Fax: 219-762-7318
Mailing address:
  • Phone: 219-513-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004119A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: