Healthcare Provider Details

I. General information

NPI: 1013266790
Provider Name (Legal Business Name): ERICK BANUELOS M.A., LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73D WINTHROP AVE
LAWRENCE MA
01843-3716
US

IV. Provider business mailing address

73D WINTHROP AVE
LAWRENCE MA
01843-3716
US

V. Phone/Fax

Practice location:
  • Phone: 978-686-0090
  • Fax:
Mailing address:
  • Phone: 978-686-3017
  • Fax: 978-685-4280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120253
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: