Healthcare Provider Details

I. General information

NPI: 1588815591
Provider Name (Legal Business Name): ERICA Y FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

IV. Provider business mailing address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-6061
  • Fax: 626-962-4471
Mailing address:
  • Phone: 626-962-6061
  • Fax: 626-962-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT34421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: