Provider Demographics
NPI:1184452518
Name:FUENTES, ANGELA SUZANNE
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:SUZANNE
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 1:90 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8138
Mailing Address - Country:US
Mailing Address - Phone:502-965-7232
Mailing Address - Fax:
Practice Address - Street 1:90 HOWARD DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8138
Practice Address - Country:US
Practice Address - Phone:502-965-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYF21486190106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician