Basic Information
| Provider Information | |||||||||
| NPI: | 1396204798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONSECA | ||||||||
| FirstName: | ERICCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4004 LIBERTY AVE | ||||||||
| Address2: | |||||||||
| City: | LA CRESCENTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912143750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187367513 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2750 E WASHINGTON BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911071449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262968900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2019 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 106H00000X | 133252 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.