Provider Demographics
NPI:1801237128
Name:FONSECA, MARILYN MARIE (MSW)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:MARIE
Last Name:FONSECA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 TANYA ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70507-4825
Mailing Address - Country:US
Mailing Address - Phone:337-278-4290
Mailing Address - Fax:
Practice Address - Street 1:103 RUE BEAUREGARD
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-278-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2148104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker