Provider Demographics
NPI:1700557386
Name:FUENTES, SAMARA
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:FUENTES
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 1:517 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:IN
Mailing Address - Zip Code:46721-1007
Mailing Address - Country:US
Mailing Address - Phone:260-645-1481
Mailing Address - Fax:
Practice Address - Street 1:915 S CLINTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2601
Practice Address - Country:US
Practice Address - Phone:260-422-5625
Practice Address - Fax:260-420-7382
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health