Provider Demographics
NPI:1194450908
Name:FERNANDEZ, LIZ K
Entity type:Individual
Prefix:
First Name:LIZ
Middle Name:K
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 1:14900 SW 82ND TER APT 207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1432
Mailing Address - Country:US
Mailing Address - Phone:305-890-4121
Mailing Address - Fax:
Practice Address - Street 1:14900 SW 82ND TER APT 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1432
Practice Address - Country:US
Practice Address - Phone:305-890-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-2222776106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-22-222776OtherBACB FLORIDA