Healthcare Provider Details

I. General information

NPI: 1508432527
Provider Name (Legal Business Name): ELSA NOEMI FARFAN M.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELSA NOEMI FONSECA M.A

II. Dates (important events)

Enumeration Date: 06/01/2021
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12550 BISCAYNE BLVD STE 507
NORTH MIAMI FL
33181-2544
US

IV. Provider business mailing address

920 NE 142ND ST
NORTH MIAMI FL
33161-3216
US

V. Phone/Fax

Practice location:
  • Phone: 786-373-3027
  • Fax: 786-802-2011
Mailing address:
  • Phone: 310-598-9140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number87768
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: