Provider Demographics
NPI:1598388159
Name:FONSECA CASTELLANOS, DAYETSI
Entity Type:Individual
Prefix:
First Name:DAYETSI
Middle Name:
Last Name:FONSECA CASTELLANOS
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 1:955 NE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-4519
Mailing Address - Country:US
Mailing Address - Phone:786-660-2830
Mailing Address - Fax:
Practice Address - Street 1:955 NE 13TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-4519
Practice Address - Country:US
Practice Address - Phone:786-660-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-118677106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty