Healthcare Provider Details

I. General information

NPI: 1245809052
Provider Name (Legal Business Name): HALEY INGRID FUENTES LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HALEY INGRID FUENTES LMFT

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W ALLUVIAL AVE STE 108
FRESNO CA
93711-5857
US

IV. Provider business mailing address

698 N CLAREMONT AVE
CLOVIS CA
93611-7304
US

V. Phone/Fax

Practice location:
  • Phone: 559-795-5990
  • Fax:
Mailing address:
  • Phone: 559-681-8311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number124427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: