Healthcare Provider Details

I. General information

NPI: 1104475524
Provider Name (Legal Business Name): BRANDON MICHAEL FONSECA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3191 W TEMPLE AVE STE 150
POMONA CA
91768-3243
US

IV. Provider business mailing address

3191 W TEMPLE AVE STE 150
POMONA CA
91768-3243
US

V. Phone/Fax

Practice location:
  • Phone: 626-206-3139
  • Fax:
Mailing address:
  • Phone: 714-409-5057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number130684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: