Provider Demographics
NPI:1477036218
Name:FUENTES, GUSTAVO (APCC ASOCIATE LICENS)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:FUENTES
Suffix:
Gender:M
Credentials:APCC ASOCIATE LICENS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-4521
Mailing Address - Country:US
Mailing Address - Phone:925-758-2124
Mailing Address - Fax:209-000-0000
Practice Address - Street 1:237 E CHANNEL ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2322
Practice Address - Country:US
Practice Address - Phone:209-444-8910
Practice Address - Fax:209-444-8905
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8321101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherMEDICARE