Provider Demographics
NPI:1518570183
Name:BANUELOS, ASHLY
Entity Type:Individual
Prefix:
First Name:ASHLY
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27777 INKSTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5326
Mailing Address - Country:US
Mailing Address - Phone:248-436-4400
Mailing Address - Fax:
Practice Address - Street 1:304 PEARL ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2684
Practice Address - Country:US
Practice Address - Phone:503-657-9889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician