MEDICARE: MRS. JOHANNA NICOLE BANKS PLCSW

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	1041C0700X	Clinical Social Worker	P005450	NC

General Provider Information

NPI Number	:	1821386160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOHANNA NICOLE BANKS PLCSW

Provider Business Mailing Address
First Line	:	10936 SAND RIVER CT
Second Line	:
City	:	DAVIDSON
State	:	NC
Zip	:	28036-9512
Country	:	US
Telephone Number	:	704-657-9217
Fax Number	:

Provider Business Practice Location Address
First Line	:	10225 HICKORYWOOD HILL AVE STE B
Second Line	:
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-3431
Country	:	US
Telephone Number	:	704-657-9217
Fax Number	:

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

Provider Enumeration Date	:	07/20/2011
Last Update Date	:	07/20/2011

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