Provider Demographics
NPI:1124441068
Name:FERNANDEZ, LIZABETH
Entity type:Individual
Prefix:
First Name:LIZABETH
Middle Name:
Last Name:FERNANDEZ
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 1:1640 W ROOSEVELT RD
Mailing Address - Street 2:MC 727
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1316
Mailing Address - Country:US
Mailing Address - Phone:312-413-1800
Mailing Address - Fax:312-413-1593
Practice Address - Street 1:1640 W ROOSEVELT RD
Practice Address - Street 2:MC 727
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1316
Practice Address - Country:US
Practice Address - Phone:312-413-1800
Practice Address - Fax:312-413-1593
Is Sole Proprietor?:No
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.014698104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker