Provider Demographics
NPI:1366000226
Name:FUENTES, EUNICE DOLORES
Entity Type:Individual
Prefix:
First Name:EUNICE
Middle Name:DOLORES
Last Name:FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4623 LENNOX BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90304-2215
Mailing Address - Country:US
Mailing Address - Phone:310-850-4623
Mailing Address - Fax:
Practice Address - Street 1:4623 LENNOX BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90304-2215
Practice Address - Country:US
Practice Address - Phone:310-850-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional