Basic Information
| Provider Information | |||||||||
| NPI: | 1497268536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUENROSTRO | ||||||||
| FirstName: | SHANEYA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16782 VON KARMAN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926062417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498332237 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 HOWE AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163501737 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2017 | ||||||||
| LastUpdateDate: | 04/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | N |
ID Information
| ID | Type | State | Issuer | Description | 11238647 | 05 | CA | MEDICAID |