Provider Demographics
NPI:1649772534
Name:BANUELOS, ANGELICA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12500 BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-9784
Mailing Address - Country:US
Mailing Address - Phone:916-874-1042
Mailing Address - Fax:
Practice Address - Street 1:12500 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-9784
Practice Address - Country:US
Practice Address - Phone:916-874-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA697861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical