Healthcare Provider Details

I. General information

NPI: 1255442638
Provider Name (Legal Business Name): CONRAD DANIEL FUENTES MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N EUCLID ST STE 300
ANAHEIM CA
92801-5506
US

IV. Provider business mailing address

312 N NEWELL PL
FULLERTON CA
92832-2032
US

V. Phone/Fax

Practice location:
  • Phone: 714-871-5646
  • Fax:
Mailing address:
  • Phone: 714-992-5285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: