Healthcare Provider Details

I. General information

NPI: 1538710041
Provider Name (Legal Business Name): MARIA FUENTES LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W HAWTHORNE AVE FL 2
VALLEY STREAM NY
11580-6220
US

IV. Provider business mailing address

94 MAIN ST APT 3
MINEOLA NY
11501-4025
US

V. Phone/Fax

Practice location:
  • Phone: 516-569-6600
  • Fax:
Mailing address:
  • Phone: 516-360-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106931-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: