Provider Demographics
NPI:1326865122
Name:FERNANDEZ, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:793 HOMESTEAD RD S
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-7651
Mailing Address - Country:US
Mailing Address - Phone:786-223-8204
Mailing Address - Fax:
Practice Address - Street 1:793 HOMESTEAD RD S
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33974-7651
Practice Address - Country:US
Practice Address - Phone:786-223-8204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-363356106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician