Provider Demographics
NPI:1174072581
Name:BANUELOS, STEPHANIE (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8003 S IH 35 APT 2724
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-0089
Mailing Address - Country:US
Mailing Address - Phone:562-212-3944
Mailing Address - Fax:
Practice Address - Street 1:3006 BEE CAVES RD STE D310
Practice Address - Street 2:
Practice Address - City:ROLLINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:78746-5753
Practice Address - Country:US
Practice Address - Phone:512-956-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39141103TC0700X, 103TC1900X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program