Healthcare Provider Details

I. General information

NPI: 1356157390
Provider Name (Legal Business Name): C. NICOLE BANKS LCSW, BEHAVIOR HEALTH, COUNSELING & CONSULTING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 HIGHLAND COLONY PARKWAY BUILDING 5000 SUITE 5203
RIDGELAND MS
39157
US

IV. Provider business mailing address

1000 HIGHLAND COLONY PARKWAY BLDG 5000 SUITE 5203
RIDGELAND MS
39157
US

V. Phone/Fax

Practice location:
  • Phone: 601-460-0464
  • Fax:
Mailing address:
  • Phone: 601-460-0464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CYL NICOLE BANKS
Title or Position: OWNER
Credential: LCSW
Phone: 601-668-7828