Provider Demographics
NPI:1629619341
Name:FONSECA, KATHERINE NICOLE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:NICOLE
Last Name:FONSECA
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 1:426 MCKEAN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2525
Mailing Address - Country:US
Mailing Address - Phone:347-225-6547
Mailing Address - Fax:
Practice Address - Street 1:1343 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5519
Practice Address - Country:US
Practice Address - Phone:610-359-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC014736225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist