Provider Demographics
NPI:1023181377
Name:FERNANDEZ, ANTONIO I (LCSW)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:I
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:ANTHONY
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 27855
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86312-7855
Mailing Address - Country:US
Mailing Address - Phone:928-533-3717
Mailing Address - Fax:
Practice Address - Street 1:3121 N ORTH WINDSONG
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314
Practice Address - Country:US
Practice Address - Phone:928-533-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11591104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ926446Medicaid