Provider Demographics
NPI:1639043169
Name:FONSECA, WILLIAM ELY
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ELY
Last Name:FONSECA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 MOUNT GOETHE WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-9077
Mailing Address - Country:US
Mailing Address - Phone:925-690-7911
Mailing Address - Fax:
Practice Address - Street 1:1887 MOUNT GOETHE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-9077
Practice Address - Country:US
Practice Address - Phone:925-690-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician