Healthcare Provider Details

I. General information

NPI: 1063052702
Provider Name (Legal Business Name): JOANNA FONSECA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 SUNSET DR STE 151
MIAMI FL
33173-3286
US

IV. Provider business mailing address

720 E 15TH PL
HIALEAH FL
33010-3231
US

V. Phone/Fax

Practice location:
  • Phone: 786-548-1022
  • Fax:
Mailing address:
  • Phone: 305-332-8559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17639
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: