Healthcare Provider Details

I. General information

NPI: 1104449032
Provider Name (Legal Business Name): LEYDI TATIANA FONSECA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 HIGHGATE RD
ITHACA NY
14850-1436
US

IV. Provider business mailing address

212 HIGHGATE RD
ITHACA NY
14850-1436
US

V. Phone/Fax

Practice location:
  • Phone: 862-264-9284
  • Fax:
Mailing address:
  • Phone: 862-264-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06006900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW025475
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06397700
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number095562-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: