Provider Demographics
NPI:1205236015
Name:BANUELOS, GINA MONIQUE (RRW)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MONIQUE
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N STATE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-1485
Mailing Address - Country:US
Mailing Address - Phone:951-652-3560
Mailing Address - Fax:951-929-2780
Practice Address - Street 1:950 N STATE ST
Practice Address - Street 2:SUITE D
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-1485
Practice Address - Country:US
Practice Address - Phone:951-652-3560
Practice Address - Fax:951-929-2780
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3339101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA333901Medicaid
CA333903Medicaid