Provider Demographics
NPI:1972160620
Name:FONSECA, ROSA ISABEL
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:ISABEL
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 1:13893 SW 258TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6728
Mailing Address - Country:US
Mailing Address - Phone:786-545-6854
Mailing Address - Fax:305-224-1479
Practice Address - Street 1:13893 SW 258TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6728
Practice Address - Country:US
Practice Address - Phone:786-545-6854
Practice Address - Fax:305-224-1479
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-80842106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician