Basic Information
| Provider Information | |||||||||
| NPI: | 1366885477 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANUELOS | ||||||||
| FirstName: | LINO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 701 SCOFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WASCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932807515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617588400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 SCOFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WASCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932807515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617588400 | ||||||||
| FaxNumber: | 6617587684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 25464 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.