Provider Demographics
NPI:1285348615
Name:FONSECA, SAMUEL ALVES (LCSW)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ALVES
Last Name:FONSECA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CODMAN ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:857-345-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228672104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty