Provider Demographics
NPI:1376661942
Name:BANUELOS, ANTONIO (LCSW)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 N ELLEN DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-2331
Mailing Address - Country:US
Mailing Address - Phone:626-534-7009
Mailing Address - Fax:
Practice Address - Street 1:17707 STUDEBAKER RD
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2640
Practice Address - Country:US
Practice Address - Phone:562-403-0688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical