Healthcare Provider Details

I. General information

NPI: 1609792738
Provider Name (Legal Business Name): MS. KIMBERLY ANITA BANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6454 KERRVILLE ROSEMARK RD
MILLINGTON TN
38053-5505
US

IV. Provider business mailing address

6454 KERRVILLE ROSEMARK RD
MILLINGTON TN
38053-5505
US

V. Phone/Fax

Practice location:
  • Phone: 901-616-7763
  • Fax:
Mailing address:
  • Phone: 901-616-7763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: