Healthcare Provider Details

I. General information

NPI: 1396204798
Provider Name (Legal Business Name): ERICCA FONSECA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 E WASHINGTON BLVD STE 230
PASADENA CA
91107-1449
US

IV. Provider business mailing address

4004 LIBERTY AVE
LA CRESCENTA CA
91214-3750
US

V. Phone/Fax

Practice location:
  • Phone: 626-296-8900
  • Fax:
Mailing address:
  • Phone: 818-736-7513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number133252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: