Provider Demographics
NPI:1124731849
Name:PUENTES, JOSEPH A IV
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:PUENTES
Suffix:IV
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 1:852 SW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-2507
Mailing Address - Country:US
Mailing Address - Phone:541-699-1525
Mailing Address - Fax:
Practice Address - Street 1:852 SW 15TH ST
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-2507
Practice Address - Country:US
Practice Address - Phone:541-699-1525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC7909101YA0400X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty