Provider Demographics
NPI:1396101028
Name:FONSECA, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FONSECA
Suffix:
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 1:215 SHUMAN BLVD
Mailing Address - Street 2:STE 401
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8458
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:978-313-6824
Practice Address - Street 1:3143 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-4733
Practice Address - Country:US
Practice Address - Phone:815-744-6898
Practice Address - Fax:815-744-2486
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3016237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist