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General NPI Number Information
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NPI Number | 1720011885
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Entity Type | Individual
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Provider Name | NANETTE DE FUENTES PH.D.
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Gender | Female
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Dates
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Enumeration Date | 07/09/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 138 N BRAND BLVD SUITE 300
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City | GLENDALE
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State | CA
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Zip | 91203-4614
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Country | US
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Telephone | 818-548-1122
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Fax | 323-254-4548
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Provider Business Mailing Address
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Address Line | 138 N BRAND BLVD SUITE 300
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City | GLENDALE
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State | CA
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Zip | 91203-4614
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Country | US
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Telephone | 818-548-1122
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Fax | 323-254-4548
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY 11400
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License Number State | CA
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