MEDICARE: MRS. TWYLA JANE BANKS MCD,CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP#1133	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5Y642	OTHER	AR	AR BCBS PROVIDER #

General Provider Information

NPI Number	:	1699829838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TWYLA JANE BANKS MCD,CCC-SLP

Provider Business Mailing Address
First Line	:	3305 LONOKE CV
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72404-9678
Country	:	US
Telephone Number	:	870-933-7213
Fax Number	:

Provider Business Practice Location Address
First Line	:	2808 FOX MEADOW LN
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72404-9346
Country	:	US
Telephone Number	:	870-932-4245
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/09/2007

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