Provider Demographics
NPI:1992260343
Name:FUENTES, YAHAYRA
Entity type:Individual
Prefix:
First Name:YAHAYRA
Middle Name:
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 1:12720 LAUREL ST UNIT 207
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2115
Mailing Address - Country:US
Mailing Address - Phone:619-917-0509
Mailing Address - Fax:
Practice Address - Street 1:12720 LAUREL ST UNIT 207
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:CA
Practice Address - Zip Code:92040-2115
Practice Address - Country:US
Practice Address - Phone:619-917-0509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAJC908819445OtherBLUE SHIELD HEALTH PLAN