Healthcare Provider Details

I. General information

NPI: 1245751718
Provider Name (Legal Business Name): EVELYN ANGELICA FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 07/21/2022
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8142 SUNLAND BLVD
SUN VALLEY CA
91352
US

IV. Provider business mailing address

10762 KESWICK ST
SUN VALLEY CA
91352-4606
US

V. Phone/Fax

Practice location:
  • Phone: 818-306-4254
  • Fax: 818-582-8836
Mailing address:
  • Phone: 818-823-4090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR4718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: