Provider Demographics
NPI:1568297562
Name:FERNANDEZ, KEILIS (RBT)
Entity type:Individual
Prefix:
First Name:KEILIS
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 NW 58TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4726
Mailing Address - Country:US
Mailing Address - Phone:786-616-4030
Mailing Address - Fax:
Practice Address - Street 1:107 ANTILLA AVE
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-3301
Practice Address - Country:US
Practice Address - Phone:305-567-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician