Provider Demographics
NPI:1083061741
Name:FONSECA FUNDORA, CANDIDO
Entity Type:Individual
Prefix:
First Name:CANDIDO
Middle Name:
Last Name:FONSECA FUNDORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 34TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-4104
Mailing Address - Country:US
Mailing Address - Phone:305-967-8074
Mailing Address - Fax:305-967-8302
Practice Address - Street 1:4116 34TH ST SW
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33976-4104
Practice Address - Country:US
Practice Address - Phone:305-967-8074
Practice Address - Fax:305-967-8302
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-17-8211106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst