Provider Demographics
NPI:1417343666
Name:BANUELOS, CESIAH (LCPC)
Entity Type:Individual
Prefix:
First Name:CESIAH
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:CESIAH
Other - Middle Name:MINERVA
Other - Last Name:BANUELOS ROBLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCPC
Mailing Address - Street 1:5006 N HERMITAGE AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2733
Mailing Address - Country:US
Mailing Address - Phone:773-310-0248
Mailing Address - Fax:
Practice Address - Street 1:3600 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2319
Practice Address - Country:US
Practice Address - Phone:773-782-2800
Practice Address - Fax:773-772-9105
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008957101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health