Provider Demographics
NPI:1710856430
Name:FONSECA, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:FONSECA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1273 OLD DANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-8116
Mailing Address - Country:US
Mailing Address - Phone:207-550-5511
Mailing Address - Fax:
Practice Address - Street 1:1273 OLD DANVILLE RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-8116
Practice Address - Country:US
Practice Address - Phone:207-550-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-31
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMT6780225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist