MEDICARE: NERCY LISBETH BASULTO FUENTES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1043782147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NERCY LISBETH BASULTO FUENTES

Provider Business Mailing Address
First Line	:	1570 DAUNTING DR
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-7658
Country	:	US
Telephone Number	:	479-882-2393
Fax Number	:	916-345-4320

Provider Business Practice Location Address
First Line	:	1035 SUNCAST LN STE 120
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9339
Country	:	US
Telephone Number	:	916-906-5578
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2018
Last Update Date	:	11/10/2025

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