Provider Demographics
NPI:1891384244
Name:FERNANDEZ, EDWIN ANTONIO (LCSW95720)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:ANTONIO
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:LCSW95720
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21736 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-2563
Mailing Address - Country:US
Mailing Address - Phone:650-704-1755
Mailing Address - Fax:
Practice Address - Street 1:1303 SAN CARLOS AVE
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2317
Practice Address - Country:US
Practice Address - Phone:650-394-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA957201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336504802Medicaid