Provider Demographics
NPI:1104449032
Name:FONSECA, LEYDI TATIANA (LCSW)
Entity type:Individual
Prefix:
First Name:LEYDI
Middle Name:TATIANA
Last Name:FONSECA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HIGHGATE RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1436
Mailing Address - Country:US
Mailing Address - Phone:862-264-9284
Mailing Address - Fax:
Practice Address - Street 1:212 HIGHGATE RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1436
Practice Address - Country:US
Practice Address - Phone:862-264-9284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06397700104100000X
NY095562-011041C0700X
NJ44SC060069001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker