Provider Demographics
NPI:1518278811
Name:FUENTES, ELIDA
Entity Type:Individual
Prefix:MRS
First Name:ELIDA
Middle Name:
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 1:420 E 3RD ST STE 910
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1647
Mailing Address - Country:US
Mailing Address - Phone:213-434-7791
Mailing Address - Fax:
Practice Address - Street 1:14623 HAWTHORNE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1581
Practice Address - Country:US
Practice Address - Phone:310-970-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
CA34109101YM0800X
CAASW 34109104100000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner