Provider Demographics
NPI:1386149300
Name:FERNANDEZ, CARLOS A
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
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 1:8335 TALBOT ST # 2
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3550
Mailing Address - Country:US
Mailing Address - Phone:305-878-2628
Mailing Address - Fax:
Practice Address - Street 1:8335 TALBOT ST # 2
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3550
Practice Address - Country:US
Practice Address - Phone:305-878-2628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician