Healthcare Provider Details

I. General information

NPI: 1457172249
Provider Name (Legal Business Name): TIFFANY FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 VIA OTONO
SAN CLEMENTE CA
92672-6017
US

IV. Provider business mailing address

752 VIA OTONO
SAN CLEMENTE CA
92672-6017
US

V. Phone/Fax

Practice location:
  • Phone: 949-485-0673
  • Fax:
Mailing address:
  • Phone: 949-485-0673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17784
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: