Provider Demographics
NPI:1720779804
Name:BANUELOS, NICOLE M (OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SARITA DR
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-6170
Mailing Address - Country:US
Mailing Address - Phone:805-824-7798
Mailing Address - Fax:
Practice Address - Street 1:2625 TOWNSGATE RD STE 102
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-5726
Practice Address - Country:US
Practice Address - Phone:805-413-3009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics