Provider Demographics
NPI:1922523869
Name:FUENTES, KALIL RAFAEL
Entity Type:Individual
Prefix:
First Name:KALIL
Middle Name:RAFAEL
Last Name:FUENTES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 SW 9TH TER APT 4
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-4444
Mailing Address - Country:US
Mailing Address - Phone:786-301-5869
Mailing Address - Fax:
Practice Address - Street 1:3451 SW 9TH TER APT 4
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-4444
Practice Address - Country:US
Practice Address - Phone:786-301-5869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician