Healthcare Provider Details

I. General information

NPI: 1598284259
Provider Name (Legal Business Name): FELIPE FONSECA, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 GLENWOOD DR
WINTER PARK FL
32792-3312
US

IV. Provider business mailing address

4820 WINDBOURNE WAY
SAINT CLOUD FL
34772-6858
US

V. Phone/Fax

Practice location:
  • Phone: 845-826-0727
  • Fax: 407-892-8346
Mailing address:
  • Phone: 845-826-0727
  • Fax: 407-892-8346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMH14147
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH14147
License Number StateFL

VIII. Authorized Official

Name: MR. BJ JOHNSON II
Title or Position: BILLING SPECIALIST
Credential:
Phone: 845-826-0727