Provider Demographics
NPI:1841476314
Name:FONSECA, ALLA (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ALLA
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MS
Other - First Name:ALLA
Other - Middle Name:
Other - Last Name:MATSIKH-ZVERINSKIY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCC/SLP
Mailing Address - Street 1:14 WOODFORD LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7927
Mailing Address - Country:US
Mailing Address - Phone:917-579-2964
Mailing Address - Fax:
Practice Address - Street 1:14 WOODFORD LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-7927
Practice Address - Country:US
Practice Address - Phone:917-579-2964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7988235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892483000Medicaid