Provider Demographics
NPI:1508003195
Name:NILLAR-FONSECA, ERNESTO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:
Last Name:NILLAR-FONSECA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9824 COLLIER LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-3184
Mailing Address - Country:US
Mailing Address - Phone:502-262-9487
Mailing Address - Fax:
Practice Address - Street 1:9824 COLLIER LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-3184
Practice Address - Country:US
Practice Address - Phone:502-262-9487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043751A103TC0700X
KY239702103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical