Provider Demographics
NPI:1639721517
Name:FONSECA, MATILDE (LMHC)
Entity Type:Individual
Prefix:
First Name:MATILDE
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12171 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-8001
Mailing Address - Country:US
Mailing Address - Phone:305-278-0200
Mailing Address - Fax:
Practice Address - Street 1:8726 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1714
Practice Address - Country:US
Practice Address - Phone:137-121-7268
Practice Address - Fax:813-915-1589
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17049101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health