Provider Demographics
NPI:1821434655
Name:DELA FUENTE, KLARISSA MAE
Entity Type:Individual
Prefix:
First Name:KLARISSA
Middle Name:MAE
Last Name:DELA FUENTE
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 1:838 SAKURA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3133
Mailing Address - Country:US
Mailing Address - Phone:209-404-9589
Mailing Address - Fax:
Practice Address - Street 1:1619 S MAIN ST
Practice Address - Street 2:108
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6260
Practice Address - Country:US
Practice Address - Phone:209-404-9589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst