Provider Demographics
NPI:1336315191
Name:FONSECA, INGRID MICHELLE
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:MICHELLE
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 1:255 WALTON BLVD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-2380
Mailing Address - Country:US
Mailing Address - Phone:561-574-6521
Mailing Address - Fax:
Practice Address - Street 1:255 WALTON BLVD
Practice Address - Street 2:SUITE #3
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-2380
Practice Address - Country:US
Practice Address - Phone:561-574-6521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No173C00000XOther Service ProvidersReflexologist
No1744G0900XOther Service ProvidersSpecialistGraphics Designer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80-0178473OtherEMPLOYER IDENTIFICATION NUMBER