Provider Demographics
NPI:1568178093
Name:FUENTES, GRETZKY K
Entity Type:Individual
Prefix:
First Name:GRETZKY
Middle Name:K
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 1:12595 SW 137TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4218
Mailing Address - Country:US
Mailing Address - Phone:305-465-9379
Mailing Address - Fax:305-203-4672
Practice Address - Street 1:12595 SW 137TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4218
Practice Address - Country:US
Practice Address - Phone:305-465-9379
Practice Address - Fax:305-203-4672
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health