Provider Demographics
NPI:1033936299
Name:FONSECA CARDENAS, LIANI
Entity type:Individual
Prefix:
First Name:LIANI
Middle Name:
Last Name:FONSECA CARDENAS
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 1:8500 SW 133RD AVENUE RD APT 103
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-4571
Mailing Address - Country:US
Mailing Address - Phone:786-561-6552
Mailing Address - Fax:
Practice Address - Street 1:9600 NW 25TH ST STE 5B
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1416
Practice Address - Country:US
Practice Address - Phone:305-522-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-375819106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty