Healthcare Provider Details

I. General information

NPI: 1487111779
Provider Name (Legal Business Name): PUENTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2019
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 VEGA CT
RALEIGH NC
27614-6940
US

IV. Provider business mailing address

2611 VEGA CT
RALEIGH NC
27614-6940
US

V. Phone/Fax

Practice location:
  • Phone: 919-399-9114
  • Fax:
Mailing address:
  • Phone: 919-399-9114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. YEIMI AMPARO SANTANA
Title or Position: GENERAL MANAGER
Credential:
Phone: 919-399-9114