Provider Demographics
NPI:1124361761
Name:DE ORNELAS, BANITA (LMFT)
Entity Type:Individual
Prefix:
First Name:BANITA
Middle Name:
Last Name:DE ORNELAS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20692
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95160-0692
Mailing Address - Country:US
Mailing Address - Phone:408-569-4994
Mailing Address - Fax:
Practice Address - Street 1:1040 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3150
Practice Address - Country:US
Practice Address - Phone:408-293-4489
Practice Address - Fax:408-293-6188
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53138106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist