Provider Demographics
NPI:1104560473
Name:FERNANDEZ, YSAURA VANESSA
Entity type:Individual
Prefix:MS
First Name:YSAURA
Middle Name:VANESSA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YSAURA
Other - Middle Name:VANESSA
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39 MCCLELLAN TER
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4516
Mailing Address - Country:US
Mailing Address - Phone:862-324-3359
Mailing Address - Fax:
Practice Address - Street 1:40 VANDERHOOF AVE
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-3138
Practice Address - Country:US
Practice Address - Phone:973-586-5243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL058528001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical