Provider Demographics
NPI:1962125203
Name:FUENTES, BERTHA A
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:A
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 1:181 E ORANGE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-5436
Mailing Address - Country:US
Mailing Address - Phone:928-581-6478
Mailing Address - Fax:
Practice Address - Street 1:3550 CAMINO DEL RIO N STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1738
Practice Address - Country:US
Practice Address - Phone:928-581-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician