Provider Demographics
NPI:1407448533
Name:PUENTES, LARRY JOSEPH (SUDRC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JOSEPH
Last Name:PUENTES
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10936 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-2724
Mailing Address - Country:US
Mailing Address - Phone:714-952-4032
Mailing Address - Fax:714-952-4075
Practice Address - Street 1:10936 DALE AVE
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-2724
Practice Address - Country:US
Practice Address - Phone:714-952-4032
Practice Address - Fax:714-952-4075
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12773101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)