Provider Demographics
NPI:1669591525
Name:FONSECA, KIM R (LICSW)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:R
Last Name:FONSECA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:RENEE
Other - Last Name:FONSECA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:12 DEARBORN ST # 3
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-2452
Mailing Address - Country:US
Mailing Address - Phone:617-997-6854
Mailing Address - Fax:
Practice Address - Street 1:12 DEARBORN ST # 3
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2452
Practice Address - Country:US
Practice Address - Phone:617-997-6854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1147811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical