Provider Demographics
NPI:1073177671
Name:FONSECA, MARY (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CIUDAD INTERAMERICANA
Mailing Address - Street 2:F14 CALLE JUREL 645
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-447-6574
Mailing Address - Fax:
Practice Address - Street 1:CARR 2 KM 8.5
Practice Address - Street 2:BO JUAN SANCHEZ
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00960
Practice Address - Country:US
Practice Address - Phone:787-782-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR738225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant