Provider Demographics
NPI:1780200766
Name:FONSECA, MYLENA
Entity Type:Individual
Prefix:
First Name:MYLENA
Middle Name:
Last Name: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 1:1200 CONCORD AVE
Mailing Address - Street 2:#100
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 CONCORD AVE
Practice Address - Street 2:#100
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520
Practice Address - Country:US
Practice Address - Phone:509-818-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician