Provider Demographics
NPI:1679904791
Name:FONSECA, FELIPE (LMHC, MCAP)
Entity Type:Individual
Prefix:
First Name:FELIPE
Middle Name:
Last Name:FONSECA
Suffix:
Gender:M
Credentials:LMHC, MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Practice Address - Street 1:4820 WINDBOURNE WAY
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-6858
Practice Address - Country:US
Practice Address - Phone:845-826-0727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-01
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14147101YM0800X
FLADC-010740-2015101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health