Provider Demographics
NPI:1134959208
Name:FONSECA VILLA, ANGELICA MARIA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIA
Last Name:FONSECA VILLA
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 1:28303 SW 132ND AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7339
Mailing Address - Country:US
Mailing Address - Phone:305-413-9979
Mailing Address - Fax:
Practice Address - Street 1:28303 SW 132ND AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7339
Practice Address - Country:US
Practice Address - Phone:305-413-9979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-363651106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician