Healthcare Provider Details

I. General information

NPI: 1376796151
Provider Name (Legal Business Name): EILEEN ELLSWORTH BANADOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 TELEGRAPH AVE
BERKELEY CA
94705-2049
US

IV. Provider business mailing address

2999 ATLANTIC ST
CONCORD CA
94518-1005
US

V. Phone/Fax

Practice location:
  • Phone: 510-926-6677
  • Fax:
Mailing address:
  • Phone: 702-241-1249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5357-C
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW86740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: