Provider Demographics
NPI:1316521081
Name:FONSECA, LAURA (MT-BC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FONSECA
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4652 COLFAX AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-1070
Mailing Address - Country:US
Mailing Address - Phone:616-733-3559
Mailing Address - Fax:
Practice Address - Street 1:4652 COLFAX AVE APT 1
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-1070
Practice Address - Country:US
Practice Address - Phone:616-733-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist