Provider Demographics
NPI:1124808654
Name:FERNANDEZ GONZALEZ, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:FERNANDEZ GONZALEZ
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 1:5951 W 16TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6886
Mailing Address - Country:US
Mailing Address - Phone:305-323-6047
Mailing Address - Fax:
Practice Address - Street 1:9867 SW 184TH ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6934
Practice Address - Country:US
Practice Address - Phone:305-323-6047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-293154106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician