Provider Demographics
NPI:1093183394
Name:FERNANDEZ, DEYDAMIA (LMSW)
Entity Type:Individual
Prefix:
First Name:DEYDAMIA
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6143 186TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2710
Mailing Address - Country:US
Mailing Address - Phone:347-506-3986
Mailing Address - Fax:
Practice Address - Street 1:20417 HILLSIDE AVE
Practice Address - Street 2:SUITE 309
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2213
Practice Address - Country:US
Practice Address - Phone:347-506-3986
Practice Address - Fax:718-475-2122
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094033104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker