Provider Demographics
NPI:1154832780
Name:BANUELOS, KASSANDRA ARIANA
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:ARIANA
Last Name:BANUELOS
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 1:2740 HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 W BULLARD AVE STE 101
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0861
Practice Address - Country:US
Practice Address - Phone:559-248-8550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA141597106H00000X
CA150145106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist