Provider Demographics
NPI:1578815411
Name:BANUELOS, INGRID STEPHANIE
Entity Type:Individual
Prefix:MISS
First Name:INGRID
Middle Name:STEPHANIE
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 1:7285 QUILL DR
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-2001
Mailing Address - Country:US
Mailing Address - Phone:562-940-6077
Mailing Address - Fax:
Practice Address - Street 1:7285 QUILL DR
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2001
Practice Address - Country:US
Practice Address - Phone:562-940-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA784381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical