Provider Demographics
NPI:1083836936
Name:FUENTES FONSECA, LOURDES (PSY D)
Entity Type:Individual
Prefix:DR
First Name:LOURDES
Middle Name:
Last Name:FUENTES FONSECA
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:LOURDES
Other - Middle Name:FUENTES
Other - Last Name:ROLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSY D
Mailing Address - Street 1:PO BOX 9023252
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00902-3252
Mailing Address - Country:US
Mailing Address - Phone:787-365-9572
Mailing Address - Fax:787-725-5886
Practice Address - Street 1:301 CALLE RECINTO S
Practice Address - Street 2:CONDOMINIO GALLARDO OFIC 401-A
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-1960
Practice Address - Country:US
Practice Address - Phone:787-365-9572
Practice Address - Fax:787-725-5886
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2108103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2466OtherAPS HUMANA
PR500950OtherFHC
PRP559OtherFIRST MEDICAL
PR56610OtherSSS