Healthcare Provider Details

I. General information

NPI: 1083550511
Provider Name (Legal Business Name): BERENICE FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DEVONSHIRE DR STE B16-18
CHAMPAIGN IL
61820-7337
US

IV. Provider business mailing address

701 DEVONSHIRE DR STE B16-18
CHAMPAIGN IL
61820-7337
US

V. Phone/Fax

Practice location:
  • Phone: 217-531-2360
  • Fax:
Mailing address:
  • Phone: 217-531-2360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: