Provider Demographics
NPI:1427076066
Name:FUENTES, GLENDA J (RPT)
Entity type:Individual
Prefix:
First Name:GLENDA
Middle Name:J
Last Name:FUENTES
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 LAKES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2924
Mailing Address - Country:US
Mailing Address - Phone:626-918-6655
Mailing Address - Fax:
Practice Address - Street 1:1135 S SUNSET AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3938
Practice Address - Country:US
Practice Address - Phone:626-732-8351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 16056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT16056AMedicare ID - Type Unspecified