Provider Demographics
NPI:1699396465
Name:LEON-FONSECA, BERENICE
Entity Type:Individual
Prefix:
First Name:BERENICE
Middle Name:
Last Name:LEON-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 1:12396 WORLD TRADE DR STE 109
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3787
Mailing Address - Country:US
Mailing Address - Phone:619-361-1168
Mailing Address - Fax:
Practice Address - Street 1:2851 CAMINO DEL RIO S STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3814
Practice Address - Country:US
Practice Address - Phone:619-361-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-02
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126980106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist