Provider Demographics
NPI:1124858436
Name:FERNANDEZ, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
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 1:16803 SARAHS PLACE
Mailing Address - Street 2:APT. 103
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714
Mailing Address - Country:US
Mailing Address - Phone:787-673-9712
Mailing Address - Fax:
Practice Address - Street 1:555 WINDERLEY
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751
Practice Address - Country:US
Practice Address - Phone:565-338-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1106743106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician