Healthcare Provider Details

I. General information

NPI: 1699449835
Provider Name (Legal Business Name): KANESHA SIMMONS BANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W TERRELL AVE
FT WORTH TX
76104-3243
US

IV. Provider business mailing address

7400 MERTON MINTER ST
SAN ANTONIO TX
78229-4404
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-3100
  • Fax:
Mailing address:
  • Phone: 210-617-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number38979
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number17055
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: