Healthcare Provider Details

I. General information

NPI: 1396054235
Provider Name (Legal Business Name): MISS HERMINIA ISABEL FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 03/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3490 THE ALAMEDA
SANTA CLARA CA
95050-4333
US

IV. Provider business mailing address

3490 THE ALAMEDA
SANTA CLARA CA
95050-4333
US

V. Phone/Fax

Practice location:
  • Phone: 408-243-0222
  • Fax:
Mailing address:
  • Phone: 408-243-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW 33606
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW 33606
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: