Provider Demographics
NPI:1720011885
Name:DE FUENTES, NANETTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANETTE
Middle Name:
Last Name:DE FUENTES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 N BRAND BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4614
Mailing Address - Country:US
Mailing Address - Phone:818-548-1122
Mailing Address - Fax:323-254-4548
Practice Address - Street 1:138 N BRAND BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4614
Practice Address - Country:US
Practice Address - Phone:818-548-1122
Practice Address - Fax:323-254-4548
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 11400103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical