1396088456 NPI number — ROBERTA CHRISTIANA WILBANKS LCSW

Table of content: ROBERTA CHRISTIANA WILBANKS LCSW (NPI 1396088456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396088456 NPI number — ROBERTA CHRISTIANA WILBANKS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILBANKS
Provider First Name:
ROBERTA
Provider Middle Name:
CHRISTIANA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HORNE
Provider Other First Name:
ROBERTA
Provider Other Middle Name:
CHRISTIANA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396088456
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
816 E OLDHAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37917-5567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-523-9163
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
816 E OLDHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37917-5567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-523-9163
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  9655 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 9655 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Q056029 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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