Provider Demographics
NPI:1346765567
Name:FONSECA RODRIGUEZ, YAN CARLOS
Entity Type:Individual
Prefix:
First Name:YAN
Middle Name:CARLOS
Last Name:FONSECA RODRIGUEZ
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 1:218 NW 12TH AVE APT 1002
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33128-2204
Mailing Address - Country:US
Mailing Address - Phone:786-259-3081
Mailing Address - Fax:
Practice Address - Street 1:218 NW 12TH AVE APT 1002
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-2204
Practice Address - Country:US
Practice Address - Phone:786-259-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty