MEDICARE: IXCHEL TELLEZ FONSECA LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	111297	CA

General Provider Information

NPI Number	:	1962777904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IXCHEL TELLEZ FONSECA LMFT

Provider Business Mailing Address
First Line	:	155 N RIVERVIEW DR
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92808-1225
Country	:	US
Telephone Number	:	714-422-5773
Fax Number	:	714-202-9870

Provider Business Practice Location Address
First Line	:	155 N RIVERVIEW DR
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92808-1225
Country	:	US
Telephone Number	:	714-422-5773
Fax Number	:	714-202-9870

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	05/17/2024

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