Provider Demographics
NPI:1720742232
Name:FUENZALIDA, MARIA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:FUENZALIDA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2522
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91610-0522
Mailing Address - Country:US
Mailing Address - Phone:818-903-5844
Mailing Address - Fax:
Practice Address - Street 1:4444 W RIVERSIDE DR STE 103
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4048
Practice Address - Country:US
Practice Address - Phone:818-579-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1040681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty