Healthcare Provider Details

I. General information

NPI: 1710335948
Provider Name (Legal Business Name): JULIE A FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 PIERCE ST STE 200
RIVERSIDE CA
92505-4400
US

IV. Provider business mailing address

11801 PIERCE ST STE 200
RIVERSIDE CA
92505-4400
US

V. Phone/Fax

Practice location:
  • Phone: 951-783-9096
  • Fax:
Mailing address:
  • Phone: 951-783-9096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number121519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: