Provider Demographics
NPI:1154800878
Name:FONSA, MIREILLE INDEM (MS)
Entity type:Individual
Prefix:MISS
First Name:MIREILLE
Middle Name:INDEM
Last Name:FONSA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9210 S WESTERN AVE STE A-21
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-4982
Mailing Address - Country:US
Mailing Address - Phone:405-676-9227
Mailing Address - Fax:
Practice Address - Street 1:9210 S WESTERN AVE STE A-21
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-4982
Practice Address - Country:US
Practice Address - Phone:405-676-9227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health