Healthcare Provider Details

I. General information

NPI: 1366885477
Provider Name (Legal Business Name): LINO BANUELOS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SCOFIELD AVE
WASCO CA
93280-7515
US

IV. Provider business mailing address

701 SCOFIELD AVE
WASCO CA
93280-7515
US

V. Phone/Fax

Practice location:
  • Phone: 661-758-8400
  • Fax: 661-758-7684
Mailing address:
  • Phone: 661-758-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: