Provider Demographics
NPI:1578211660
Name:BANKS, EARL DWAYNE (LPC)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:DWAYNE
Last Name:BANKS
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 1:4611 RIVER HILL CIR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1884
Mailing Address - Country:US
Mailing Address - Phone:678-464-3275
Mailing Address - Fax:
Practice Address - Street 1:4611 RIVER HILL CIR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-1884
Practice Address - Country:US
Practice Address - Phone:678-464-3275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC001765101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional