Provider Demographics
NPI:1114806353
Name:FONSECA, CARLOS JR
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:FONSECA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 NE POMONA ST APT 106
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-8053
Mailing Address - Country:US
Mailing Address - Phone:541-827-9436
Mailing Address - Fax:
Practice Address - Street 1:901 MAIN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-5810
Practice Address - Country:US
Practice Address - Phone:541-238-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-01
Last Update Date:2025-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator