Provider Demographics
NPI:1245621754
Name:FONSECA, ELISABETH R (PHD)
Entity type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:R
Last Name:FONSECA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 5TH AVE
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-4509
Mailing Address - Country:US
Mailing Address - Phone:212-683-3339
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE
Practice Address - Street 2:SUITE 1101
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4509
Practice Address - Country:US
Practice Address - Phone:212-683-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013336-1103TC0700X
MA9868103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical