Provider Demographics
NPI:1114604758
Name:FONSECA TORANZO, LUIS ROBERTO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ROBERTO
Last Name:FONSECA TORANZO
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 1:1885 W 56TH ST APT 401
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7361
Mailing Address - Country:US
Mailing Address - Phone:786-647-4789
Mailing Address - Fax:
Practice Address - Street 1:1885 W 56TH ST APT 401
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7361
Practice Address - Country:US
Practice Address - Phone:786-647-4789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT23278810106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician