Healthcare Provider Details

I. General information

NPI: 1215641527
Provider Name (Legal Business Name): EDWIN FONSECA MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 S RAYMOND RD
SPOKANE VALLEY WA
99206-3534
US

IV. Provider business mailing address

1102 S RAYMOND RD
SPOKANE VALLEY WA
99206-3534
US

V. Phone/Fax

Practice location:
  • Phone: 509-892-4342
  • Fax:
Mailing address:
  • Phone: 509-892-4342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: