=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043918485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. SHIQUITA BANKS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2023
-----------------------------------------------------
Last Update Date | 02/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3077 W JEFFERSON ST
-----------------------------------------------------
City | JOLIET
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60435-5262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-200-9545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 CEDARWOOD DR UNIT F
-----------------------------------------------------
City | CREST HILL
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60403-5122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-841-1046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 178.017713
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------