Provider Demographics
NPI:1740012996
Name:BUENROSTRO, PRISCILLA
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:BUENROSTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14071 PEYTON DR UNIT 1605
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-7169
Mailing Address - Country:US
Mailing Address - Phone:909-231-7366
Mailing Address - Fax:
Practice Address - Street 1:350 W BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92223-4073
Practice Address - Country:US
Practice Address - Phone:951-769-4391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10409101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor