Provider Demographics
NPI:1912617432
Name:FUENTES, ANTONIO
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
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 1:3310 MAIN AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4067
Mailing Address - Country:US
Mailing Address - Phone:210-392-6677
Mailing Address - Fax:
Practice Address - Street 1:3310 MAIN AVE APT 205
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4067
Practice Address - Country:US
Practice Address - Phone:210-392-6677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No177F00000XOther Service ProvidersLodging