Provider Demographics
NPI:1497066542
Name:DE LA FUENTE, EVELIO
Entity Type:Individual
Prefix:
First Name:EVELIO
Middle Name:
Last Name:DE LA FUENTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SW 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-3113
Mailing Address - Country:US
Mailing Address - Phone:305-261-8023
Mailing Address - Fax:305-261-4579
Practice Address - Street 1:165 SW 63RD AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-3113
Practice Address - Country:US
Practice Address - Phone:305-261-8023
Practice Address - Fax:305-261-4579
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health