Healthcare Provider Details

I. General information

NPI: 1457283731
Provider Name (Legal Business Name): DIANA FUENTES
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N JACKSON ST
GLENDALE CA
91206-4334
US

IV. Provider business mailing address

630 E 41ST PL
LOS ANGELES CA
90011-3125
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-3111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number6650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: