Provider Demographics
NPI:1750974317
Name:DOMINGUEZ-BANUELOS, MONICA (MSW)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:DOMINGUEZ-BANUELOS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1266 AMBER CT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3682
Mailing Address - Country:US
Mailing Address - Phone:331-210-3790
Mailing Address - Fax:
Practice Address - Street 1:1500 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3990
Practice Address - Country:US
Practice Address - Phone:779-777-7933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.015666104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker