Healthcare Provider Details

I. General information

NPI: 1962801795
Provider Name (Legal Business Name): STEPHANIE FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE MARES

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 E SAN JACINTO AVE
PERRIS CA
92570-2878
US

IV. Provider business mailing address

308 E SAN JACINTO AVE
PERRIS CA
92570-2878
US

V. Phone/Fax

Practice location:
  • Phone: 951-943-1130
  • Fax:
Mailing address:
  • Phone: 951-943-1130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: