Healthcare Provider Details

I. General information

NPI: 1659758399
Provider Name (Legal Business Name): DANIEL MIRANDA FONSECA MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COND MAGNOLIA GDNS P-12
BAYAMON PR
00956-7100
US

IV. Provider business mailing address

COND MAGNOLIA GDNS P-12
BAYAMON PR
00956-7100
US

V. Phone/Fax

Practice location:
  • Phone: 787-785-9282
  • Fax: 787-200-0482
Mailing address:
  • Phone: 787-785-9282
  • Fax: 787-200-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12842
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier12842
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerLICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: