Provider Demographics
NPI:1124688932
Name:FERNANDEZ, MARCO ANTONIO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
Last Name:FERNANDEZ
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 1:355 DOVER PKWY
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-3440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 DOVER PKWY STE B
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-3441
Practice Address - Country:US
Practice Address - Phone:661-725-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1082571041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health