MEDICARE: SELENA BRIANA BUENO LCSW 106504

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	106504	CA

General Provider Information

NPI Number	:	1194208033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELENA BRIANA BUENO LCSW 106504

Provider Business Mailing Address
First Line	:	27261 LAS RAMBLAS STE 220
Second Line	:
City	:	MISSION VIEJO
State	:	CA
Zip	:	92691-6468
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11755 WILSHIRE BLVD BLDG STE 1250
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-1506
Country	:	US
Telephone Number	:	415-449-2813
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	04/10/2023

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