Provider Demographics
NPI:1164029625
Name:BANUELOS, ALEJANDRO
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 W 14TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215-4848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8805 W 14TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215-4848
Practice Address - Country:US
Practice Address - Phone:303-989-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician