Provider Demographics
NPI:1992512180
Name:FONSECA, KATHERYN MICHELLE
Entity type:Individual
Prefix:
First Name:KATHERYN
Middle Name:MICHELLE
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 1:105 RAVENCREST DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-4856
Mailing Address - Country:US
Mailing Address - Phone:469-954-2322
Mailing Address - Fax:
Practice Address - Street 1:402 GENERAL COURTNEY HODGES BLVD STE 202
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-3206
Practice Address - Country:US
Practice Address - Phone:478-343-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB1224449106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician