Healthcare Provider Details

I. General information

NPI: 1639602691
Provider Name (Legal Business Name): ANA FUENTES CALDERON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7253 PURDUE AVE
LA MESA CA
91942-5919
US

IV. Provider business mailing address

16255 VENTURA BLVD STE 900
ENCINO CA
91436-2317
US

V. Phone/Fax

Practice location:
  • Phone: 619-844-7736
  • Fax:
Mailing address:
  • Phone: 801-823-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-46457
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-17-7616
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: