Provider Demographics
NPI:1407109366
Name:FONSECA, TOMAS FERNANDO (BS)
Entity type:Individual
Prefix:
First Name:TOMAS
Middle Name:FERNANDO
Last Name:FONSECA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 NW DOROTHY ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1411
Mailing Address - Country:US
Mailing Address - Phone:561-667-1354
Mailing Address - Fax:
Practice Address - Street 1:1986 31ST AVE STE 120
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6627
Practice Address - Country:US
Practice Address - Phone:561-616-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker