Provider Demographics
NPI:1104417526
Name:FUENTES, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FUENTES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-7595
Mailing Address - Country:US
Mailing Address - Phone:925-999-4199
Mailing Address - Fax:
Practice Address - Street 1:1020 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-4521
Practice Address - Country:US
Practice Address - Phone:209-336-8206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health