Provider Demographics
NPI:1124766266
Name:FUENTES, LORIE ESTHER
Entity type:Individual
Prefix:MS
First Name:LORIE
Middle Name:ESTHER
Last Name:FUENTES
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 1:4222 W POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-1854
Mailing Address - Country:US
Mailing Address - Phone:773-818-9430
Mailing Address - Fax:773-687-9412
Practice Address - Street 1:2715 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1351
Practice Address - Country:US
Practice Address - Phone:773-360-1389
Practice Address - Fax:773-687-9412
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
IL150.108067104100000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker