Provider Demographics
NPI:1104949452
Name:FUENTES, DAINERY M (PHD)
Entity type:Individual
Prefix:DR
First Name:DAINERY
Middle Name:M
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5897 LAKE VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4711
Mailing Address - Country:US
Mailing Address - Phone:863-648-1812
Mailing Address - Fax:
Practice Address - Street 1:464 W PIPKIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2699
Practice Address - Country:US
Practice Address - Phone:863-648-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY004076103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical