Provider Demographics
NPI:1205321635
Name:FONTELA, LARITZA Y
Entity type:Individual
Prefix:
First Name:LARITZA
Middle Name:Y
Last Name:FONTELA
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 1:11051 SW 200TH ST APT 204
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8401
Mailing Address - Country:US
Mailing Address - Phone:786-267-2747
Mailing Address - Fax:
Practice Address - Street 1:11051 SW 200TH ST APT 204
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-8401
Practice Address - Country:US
Practice Address - Phone:786-267-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF534539899240106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician