Provider Demographics
NPI:1780348516
Name:FONSECA, TIA MARIE
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:MARIE
Last Name: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 1:562 MICHELLE CT APT 22
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-3204
Mailing Address - Country:US
Mailing Address - Phone:859-322-5553
Mailing Address - Fax:
Practice Address - Street 1:925 DUDLEY PIKE
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-8120
Practice Address - Country:US
Practice Address - Phone:859-360-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician