Healthcare Provider Details

I. General information

NPI: 1083061741
Provider Name (Legal Business Name): CANDIDO FONSECA FUNDORA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2016
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 GOLDENROD AVE
MARCO ISLAND FL
34145-2762
US

IV. Provider business mailing address

1075 GOLDENROD AVE
MARCO ISLAND FL
34145-2762
US

V. Phone/Fax

Practice location:
  • Phone: 305-967-8074
  • Fax: 305-967-8302
Mailing address:
  • Phone: 305-967-8074
  • Fax: 305-967-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-17-8211
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: