Provider Demographics
NPI:1043782147
Name:BASULTO FUENTES, NERCY LISBETH
Entity type:Individual
Prefix:
First Name:NERCY
Middle Name:LISBETH
Last Name:BASULTO FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NERCY
Other - Middle Name:LISBETH
Other - Last Name:PADILLA-FUENTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1570 DAUNTING DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-7658
Mailing Address - Country:US
Mailing Address - Phone:479-882-2393
Mailing Address - Fax:916-345-4320
Practice Address - Street 1:1035 SUNCAST LN STE 120
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9339
Practice Address - Country:US
Practice Address - Phone:916-345-4320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-30
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist