Provider Demographics
NPI:1104688605
Name:FUENTES CARDENO, MARIANA
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:FUENTES CARDENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 ENSIGN AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3949
Mailing Address - Country:US
Mailing Address - Phone:707-308-8433
Mailing Address - Fax:
Practice Address - Street 1:1300 ETHAN WAY STE 200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2277
Practice Address - Country:US
Practice Address - Phone:916-800-2872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician