Provider Demographics
NPI:1013266790
Name:BANUELOS, ERICK (MA, LCSW)
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:M
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73D WINTHROP AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-3716
Mailing Address - Country:US
Mailing Address - Phone:978-686-3017
Mailing Address - Fax:978-685-4280
Practice Address - Street 1:73D WINTHROP AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-3716
Practice Address - Country:US
Practice Address - Phone:978-686-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1202531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical