Provider Demographics
NPI:1750668539
Name:FONSECA, ANGELA MARIE (LADCI CAS)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:MARIE
Last Name:FONSECA
Suffix:
Gender:F
Credentials:LADCI CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 TWIN LAKES DR
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:MA
Mailing Address - Zip Code:02338-2229
Mailing Address - Country:US
Mailing Address - Phone:781-294-4123
Mailing Address - Fax:
Practice Address - Street 1:62 WALDECK ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1329
Practice Address - Country:US
Practice Address - Phone:617-265-2636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility