Provider Demographics
NPI:1518694918
Name:FUENTES, GENISE GERMAIN
Entity Type:Individual
Prefix:
First Name:GENISE
Middle Name:GERMAIN
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 1:3000 PEGASUS PARK DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-6204
Mailing Address - Country:US
Mailing Address - Phone:469-621-8500
Mailing Address - Fax:
Practice Address - Street 1:3000 PEGASUS PARK DR STE 1100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-6204
Practice Address - Country:US
Practice Address - Phone:469-621-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106321235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist