Provider Demographics
NPI:1710630553
Name:FONSECA, ZOE NYMAHWAYH SCOUT (OTR/L)
Entity Type:Individual
Prefix:
First Name:ZOE
Middle Name:NYMAHWAYH SCOUT
Last Name:FONSECA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:NOCONA
Mailing Address - State:TX
Mailing Address - Zip Code:76255-9365
Mailing Address - Country:US
Mailing Address - Phone:505-219-7694
Mailing Address - Fax:
Practice Address - Street 1:3006 MCNIEL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4954
Practice Address - Country:US
Practice Address - Phone:940-691-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122397225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist