Provider Demographics
NPI:1114514908
Name:FUENTES, ABDIEL ISAI (OTR/L)
Entity Type:Individual
Prefix:
First Name:ABDIEL
Middle Name:ISAI
Last Name:FUENTES
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77564 COUNTRY CLUB DR STE 340
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-0450
Mailing Address - Country:US
Mailing Address - Phone:760-772-2838
Mailing Address - Fax:
Practice Address - Street 1:77564 COUNTRY CLUB DR STE 340
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0450
Practice Address - Country:US
Practice Address - Phone:760-772-2838
Practice Address - Fax:760-772-2838
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21393225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist