Provider Demographics
NPI:1598284259
Name:FELIPE FONSECA, LLC.
Entity Type:Organization
Organization Name:FELIPE FONSECA, LLC.
Other - Org Name:INNER PEACE AWARENESS COUNSELING, LLC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BJ
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:845-826-0727
Mailing Address - Street 1:4820 WINDBOURNE WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-6858
Mailing Address - Country:US
Mailing Address - Phone:845-826-0727
Mailing Address - Fax:407-892-8346
Practice Address - Street 1:2260 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3312
Practice Address - Country:US
Practice Address - Phone:845-826-0727
Practice Address - Fax:407-892-8346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14147101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL601184189OtherMAGELLAN
FL4879059OtherAETNA
FL020576300Medicaid
FLQJK6XOtherBLUE CROSS BLUE SHIELD