Provider Demographics
NPI:1073331864
Name:FONDEUR, LUISA
Entity type:Individual
Prefix:
First Name:LUISA
Middle Name:
Last Name:FONDEUR
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 1:6420 BOCA DEL MAR DR APT 506
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-5708
Mailing Address - Country:US
Mailing Address - Phone:754-273-1796
Mailing Address - Fax:
Practice Address - Street 1:6420 BOCA DEL MAR DR APT 506
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5708
Practice Address - Country:US
Practice Address - Phone:754-273-1796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1113318103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst