Provider Demographics
NPI:1538911458
Name:FONSECA, SUSETH ADRIANA
Entity type:Individual
Prefix:
First Name:SUSETH
Middle Name:ADRIANA
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 1:437 E 98TH ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15720 VENTURA BLVD STE 420
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4711
Practice Address - Country:US
Practice Address - Phone:818-927-0478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14560101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional