Provider Demographics
NPI:1710339650
Name:BANIWAS, KATHLEEN (LMFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BANIWAS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 SHADOWRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-7986
Mailing Address - Country:US
Mailing Address - Phone:760-599-2471
Mailing Address - Fax:
Practice Address - Street 1:780 SHADOWRIDGE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-7986
Practice Address - Country:US
Practice Address - Phone:760-599-2471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-04
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF89556106H00000X
CA1078131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL