Provider Demographics
NPI:1346045036
Name:MADERO FUENTES, GLENDA LEYLANI
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:LEYLANI
Last Name:MADERO FUENTES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 W OLD SHAKOPEE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2684
Mailing Address - Country:US
Mailing Address - Phone:952-405-9937
Mailing Address - Fax:952-303-4837
Practice Address - Street 1:6300 W OLD SHAKOPEE RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55438-2684
Practice Address - Country:US
Practice Address - Phone:952-405-9937
Practice Address - Fax:952-303-4837
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician