Healthcare Provider Details

I. General information

NPI: 1467746834
Provider Name (Legal Business Name): STACEY FONSECA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2843 S COUNTY TRL STE 123
EAST GREENWICH RI
02818-1753
US

IV. Provider business mailing address

2843 S COUNTY TRL STE 123
EAST GREENWICH RI
02818-1753
US

V. Phone/Fax

Practice location:
  • Phone: 401-402-0018
  • Fax:
Mailing address:
  • Phone: 401-402-0018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS02227
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPS02227
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPS02227
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS02227
License Number StateRI
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS02227
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: