Healthcare Provider Details

I. General information

NPI: 1710856430
Provider Name (Legal Business Name): DANIEL FONSECA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1273 OLD DANVILLE RD
AUBURN ME
04210-8116
US

IV. Provider business mailing address

1273 OLD DANVILLE RD
AUBURN ME
04210-8116
US

V. Phone/Fax

Practice location:
  • Phone: 207-550-5511
  • Fax:
Mailing address:
  • Phone: 207-550-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT6780
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: