Provider Demographics
NPI:1497883912
Name:FUENTES, ANGELICA VERGARA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:VERGARA
Last Name:FUENTES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:
Other - Last Name:VERGARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5119 RAPHAEL ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-3234
Mailing Address - Country:US
Mailing Address - Phone:310-804-7653
Mailing Address - Fax:
Practice Address - Street 1:3751 STOCKER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008
Practice Address - Country:US
Practice Address - Phone:323-298-3680
Practice Address - Fax:323-292-0053
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical