Provider Demographics
NPI:1174298145
Name:FUENTES, SAMUEL-ALEJANDRO DE JESUS (MA, LPC)
Entity Type:Individual
Prefix:
First Name:SAMUEL-ALEJANDRO
Middle Name:DE JESUS
Last Name:FUENTES
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 ANDREW ST
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2136
Mailing Address - Country:US
Mailing Address - Phone:210-748-7318
Mailing Address - Fax:
Practice Address - Street 1:1433 ANDREW ST
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2136
Practice Address - Country:US
Practice Address - Phone:210-748-7318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82655101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional