Healthcare Provider Details

I. General information

NPI: 1700165867
Provider Name (Legal Business Name): CINDY L FONSECA-SHIVERS LPC, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CINDY L FONSECA LPC, LCSW

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1794 ALLOUEZ AVE SUITE C, NUMBER 243
GREEN BAY WI
54311-6281
US

IV. Provider business mailing address

1794 ALLOUEZ AVE SUITE C, NUMBER 243
GREEN BAY WI
54311-6281
US

V. Phone/Fax

Practice location:
  • Phone: 920-367-4025
  • Fax:
Mailing address:
  • Phone: 920-367-4025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2359-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4233-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: