Basic Information
| Provider Information | |||||||||
| NPI: | 1518277656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LEON FUENTES | ||||||||
| FirstName: | CYNTHIA | ||||||||
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| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4760 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3103985690 | ||||||||
| Practice Location | |||||||||
| Address1: | 12420 VENICE BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900663841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107511200 | ||||||||
| FaxNumber: | 3103980312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 09/18/2015 | ||||||||
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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 | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 69708 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.