Provider Demographics
NPI:1588482194
Name:BANUELOS, REBECA
Entity type:Individual
Prefix:
First Name:REBECA
Middle Name:
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 1:13952 LOS ANGELES ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3051
Mailing Address - Country:US
Mailing Address - Phone:626-646-6866
Mailing Address - Fax:
Practice Address - Street 1:1441 SANTA ANITA AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-3311
Practice Address - Country:US
Practice Address - Phone:626-646-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool