1467592253 NPI number — PATRICIA FONSECA CADC

Table of content: PATRICIA FONSECA CADC (NPI 1467592253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467592253 NPI number — PATRICIA FONSECA CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONSECA
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467592253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1430 TOWERS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08701-5447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-905-9404
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 AIRPORT ROAD
Provider Second Line Business Practice Location Address:
PREFERRED BEHAVIORAL HEALTH
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-367-4700
Provider Business Practice Location Address Fax Number:
732-364-2253
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  37CA00045200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0029807 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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