Healthcare Provider Details

I. General information

NPI: 1306076880
Provider Name (Legal Business Name): MICHELLE E FONSECA LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 07/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SYCAMORE RD SUITE 330
MONTOURSVILLE PA
17754-9303
US

IV. Provider business mailing address

1500 SYCAMORE RD SUITE 330
MONTOURSVILLE PA
17754-9303
US

V. Phone/Fax

Practice location:
  • Phone: 570-322-5051
  • Fax: 570-322-6788
Mailing address:
  • Phone: 570-322-5051
  • Fax: 570-322-6788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW126880
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: