Healthcare Provider Details

I. General information

NPI: 1831739507
Provider Name (Legal Business Name): BRENDA J FUENTES GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14433 S HARRIS AVE
COMPTON CA
90221-2422
US

IV. Provider business mailing address

14433 S HARRIS AVE
COMPTON CA
90221-2422
US

V. Phone/Fax

Practice location:
  • Phone: 323-793-3105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12478635
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-36462
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: