Healthcare Provider Details

I. General information

NPI: 1881529956
Provider Name (Legal Business Name): LIZETH BANUELOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 N POWER RD STE 127
MESA AZ
85215-2911
US

IV. Provider business mailing address

PO BOX 127
KEOKUK IA
52632-0127
US

V. Phone/Fax

Practice location:
  • Phone: 480-847-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-24934
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: