Provider Demographics
NPI:1306626916
Name:PUENTES QUENGUAN, BELICE
Entity type:Individual
Prefix:
First Name:BELICE
Middle Name:
Last Name:PUENTES QUENGUAN
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 1:100 RIVERS EDGE DR UNIT 318
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5470
Mailing Address - Country:US
Mailing Address - Phone:617-435-4833
Mailing Address - Fax:
Practice Address - Street 1:302 EUSTIS ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-3800
Practice Address - Country:US
Practice Address - Phone:617-435-4833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor