Basic Information
| Provider Information | |||||||||
| NPI: | 1497883912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUENTES | ||||||||
| FirstName: | ANGELICA | ||||||||
| MiddleName: | VERGARA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VERGARA | ||||||||
| OtherFirstName: | ANGELICA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5119 RAPHAEL ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900423234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108047653 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3751 STOCKER ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232983680 | ||||||||
| FaxNumber: | 3232920053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 27397 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.