Provider Demographics
NPI:1639831084
Name:DE LA FUENTE, ROSE MARIE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:MARIE
Last Name:DE LA FUENTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:MARIE
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6623 S MASON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-1535
Mailing Address - Country:US
Mailing Address - Phone:509-793-3830
Mailing Address - Fax:
Practice Address - Street 1:711 S 25TH ST STE B
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4306
Practice Address - Country:US
Practice Address - Phone:253-536-2881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor