Provider Demographics
NPI:1225872997
Name:MESA FONSECA, GREISEL
Entity type:Individual
Prefix:
First Name:GREISEL
Middle Name:
Last Name:MESA FONSECA
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 1:2225 E 113TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6248
Mailing Address - Country:US
Mailing Address - Phone:813-992-4752
Mailing Address - Fax:
Practice Address - Street 1:801 W BAY DR STE 405
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3220
Practice Address - Country:US
Practice Address - Phone:786-479-8592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician