Provider Demographics
NPI:1316082886
Name:FERNANDEZ, LIDETTE REBECCA
Entity type:Individual
Prefix:
First Name:LIDETTE
Middle Name:REBECCA
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 1:7474 NW 167TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4151
Mailing Address - Country:US
Mailing Address - Phone:305-965-5465
Mailing Address - Fax:
Practice Address - Street 1:6447 MIAMI LAKES DR
Practice Address - Street 2:SUITE 105
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2741
Practice Address - Country:US
Practice Address - Phone:786-365-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3958225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889913400Medicaid