Provider Demographics
NPI:1447269147
Name:BANKA, GREGORY (LPC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BANKA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 DEBORAH RD SE
Mailing Address - Street 2:SUITE 202C
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1058
Mailing Address - Country:US
Mailing Address - Phone:505-859-7734
Mailing Address - Fax:505-859-7602
Practice Address - Street 1:1424 DEBORAH RD SE
Practice Address - Street 2:SUITE 202C
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1058
Practice Address - Country:US
Practice Address - Phone:505-859-7734
Practice Address - Fax:505-859-7602
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLPC: 2379101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98207326Medicaid