Healthcare Provider Details

I. General information

NPI: 1972118024
Provider Name (Legal Business Name): IRENE FONSECA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SW 66TH AVE
MIAMI FL
33144-2910
US

IV. Provider business mailing address

110 SW 66TH AVE
MIAMI FL
33144-2910
US

V. Phone/Fax

Practice location:
  • Phone: 786-458-9485
  • Fax:
Mailing address:
  • Phone: 786-458-9485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: