Provider Demographics
NPI:1548781073
Name:FUENTES, ODALIS
Entity Type:Individual
Prefix:
First Name:ODALIS
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 1:21340 SW 112TH AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2928
Mailing Address - Country:US
Mailing Address - Phone:786-612-0055
Mailing Address - Fax:
Practice Address - Street 1:21340 SW 112TH AVE APT 306
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-2928
Practice Address - Country:US
Practice Address - Phone:786-612-0055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty