Provider Demographics
NPI:1467592253
Name:FONSECA, PATRICIA (CADC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 TOWERS ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5447
Mailing Address - Country:US
Mailing Address - Phone:732-905-9404
Mailing Address - Fax:
Practice Address - Street 1:700 AIRPORT ROAD
Practice Address - Street 2:PREFERRED BEHAVIORAL HEALTH
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-367-4700
Practice Address - Fax:732-364-2253
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37CA00045200101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid
NJ0029807Medicaid