Provider Demographics
NPI:1215007620
Name:FUENTES, RAFAEL E (MS)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:E
Last Name:FUENTES
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4073 DOLPHIN DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-7326
Mailing Address - Country:US
Mailing Address - Phone:813-732-6876
Mailing Address - Fax:813-933-4625
Practice Address - Street 1:8019 N HIMES AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2712
Practice Address - Country:US
Practice Address - Phone:813-732-6876
Practice Address - Fax:813-933-4625
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLI.M.C. 5865101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health