Provider Demographics
NPI:1528533528
Name:FONSECA, ODALYS
Entity type:Individual
Prefix:
First Name:ODALYS
Middle Name:
Last Name: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 1:3105 NW 107TH AVE STE 433
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2185
Mailing Address - Country:US
Mailing Address - Phone:786-715-8511
Mailing Address - Fax:
Practice Address - Street 1:3105 NW 107TH AVE STE 433
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2185
Practice Address - Country:US
Practice Address - Phone:786-715-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-20-11440106E00000X
FLRBT-1866763106S00000X
FL1-21-56209103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician