Provider Demographics
NPI:1780736827
Name:FONSECA, ERNEST OLIVEIRA (MED)
Entity type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:OLIVEIRA
Last Name:FONSECA
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BROOKLEDGE ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-2202
Mailing Address - Country:US
Mailing Address - Phone:617-445-4467
Mailing Address - Fax:
Practice Address - Street 1:1581 BEACON ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4602
Practice Address - Country:US
Practice Address - Phone:617-445-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3620101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health