Healthcare Provider Details

I. General information

NPI: 1063842631
Provider Name (Legal Business Name): EDWARD RAYMOND FUENTES JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14140 BEACH BLVD STE 223
WESTMINSTER CA
92683-4453
US

IV. Provider business mailing address

14140 BEACH BLVD STE 223
WESTMINSTER CA
92683-4453
US

V. Phone/Fax

Practice location:
  • Phone: 714-896-7566
  • Fax:
Mailing address:
  • Phone: 714-896-7566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number105637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: