Provider Demographics
NPI:1285102301
Name:FERNANDEZ, LAURENCE (LCSW)
Entity type:Individual
Prefix:MR
First Name:LAURENCE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 ADLA DR
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-1806
Mailing Address - Country:US
Mailing Address - Phone:347-666-0397
Mailing Address - Fax:
Practice Address - Street 1:97 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4410
Practice Address - Country:US
Practice Address - Phone:203-579-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0096321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty