Provider Demographics
NPI:1821340480
Name:BANEGAS, GENEVIEVE MARILYN (LCSW, PPSC)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:MARILYN
Last Name:BANEGAS
Suffix:
Gender:F
Credentials:LCSW, PPSC
Other - Prefix:
Other - First Name:GENEVIEVE
Other - Middle Name:MARILYN
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2325
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-2325
Mailing Address - Country:US
Mailing Address - Phone:909-802-6135
Mailing Address - Fax:
Practice Address - Street 1:205 SOUTH ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-961-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 1041C0700X, 225400000X
CA775531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner