Provider Demographics
NPI:1003422908
Name:FONSECA AVILA, FREDY MANUEL SR (RBT)
Entity Type:Individual
Prefix:
First Name:FREDY
Middle Name:MANUEL
Last Name:FONSECA AVILA
Suffix:SR
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 NW 16TH STREET RD APT 236
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-1482
Mailing Address - Country:US
Mailing Address - Phone:786-865-1297
Mailing Address - Fax:
Practice Address - Street 1:8245 NW 36TH ST STE 7
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6636
Practice Address - Country:US
Practice Address - Phone:305-594-5658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-118657106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician