Provider Demographics
NPI:1124899109
Name:FERNANDEZ, DAVID RICHARD
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
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 1:1209 33RD ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-3202
Mailing Address - Country:US
Mailing Address - Phone:727-698-1333
Mailing Address - Fax:
Practice Address - Street 1:9309 CENTER ST STE 101
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5599
Practice Address - Country:US
Practice Address - Phone:703-546-1834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRBT-23-318330106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician