Provider Demographics
NPI:1255082640
Name:DA FONSECA, LUCIANA
Entity type:Individual
Prefix:
First Name:LUCIANA
Middle Name:
Last Name:DA 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 1:4500 N 32ND ST STE 119
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3350
Mailing Address - Country:US
Mailing Address - Phone:602-888-7025
Mailing Address - Fax:
Practice Address - Street 1:4500 N 32ND ST STE 119
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3350
Practice Address - Country:US
Practice Address - Phone:602-888-7025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC17066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional