Provider Demographics
NPI:1144279746
Name:BANKS, IVA JILL (PHD)
Entity type:Individual
Prefix:DR
First Name:IVA
Middle Name:JILL
Last Name:BANKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4120
Mailing Address - Country:US
Mailing Address - Phone:843-383-4746
Mailing Address - Fax:
Practice Address - Street 1:300 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-3742
Practice Address - Country:US
Practice Address - Phone:843-383-8099
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC524103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC254OtherLICENSED COUNSELING PSYCH
SC1080OtherPROFESSIONAL COUNSELOR SU
SCPS0119Medicaid