Provider Demographics
NPI:1144892209
Name:BANKERT, JUSTINE A (BCBA)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:A
Last Name:BANKERT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13322-1101
Mailing Address - Country:US
Mailing Address - Phone:315-794-1307
Mailing Address - Fax:
Practice Address - Street 1:2608 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6003
Practice Address - Country:US
Practice Address - Phone:315-797-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12150673103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst