Provider Demographics
NPI:1003045485
Name:FONSECA, LIZETH CHRISTINE
Entity Type:Individual
Prefix:MISS
First Name:LIZETH
Middle Name:CHRISTINE
Last Name:FONSECA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3103
Mailing Address - Country:US
Mailing Address - Phone:626-583-3963
Mailing Address - Fax:
Practice Address - Street 1:3280 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3103
Practice Address - Country:US
Practice Address - Phone:626-583-3963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106092106H00000X
CA98219106H00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner