Provider Demographics
NPI:1891279477
Name:PADRON FONSECA, IRALYS
Entity Type:Individual
Prefix:
First Name:IRALYS
Middle Name:
Last Name:PADRON 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 1:6829 MIDPARK CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-5383
Mailing Address - Country:US
Mailing Address - Phone:702-759-2308
Mailing Address - Fax:
Practice Address - Street 1:6829 MIDPARK CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-5383
Practice Address - Country:US
Practice Address - Phone:702-759-2308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor