=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760040547
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA BANKS BSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2019
-----------------------------------------------------
Last Update Date | 06/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 CHURCH ST
-----------------------------------------------------
City | PORT GIBSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39150-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-437-5504
-----------------------------------------------------
Fax | 601-437-5505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 CHURCH ST
-----------------------------------------------------
City | PORT GIBSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39150-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-437-5504
-----------------------------------------------------
Fax | 601-437-5506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------