Provider Demographics
NPI:1154633030
Name:FERNANDEZ, MARITZA (LCSW-R, CASAC)
Entity Type:Individual
Prefix:DR
First Name:MARITZA
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LCSW-R, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-2417
Mailing Address - Country:US
Mailing Address - Phone:718-589-2440
Mailing Address - Fax:
Practice Address - Street 1:1065 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-2417
Practice Address - Country:US
Practice Address - Phone:718-589-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2023-05-11
Deactivation Date:2023-03-02
Deactivation Code:
Reactivation Date:2023-05-04
Provider Licenses
StateLicense IDTaxonomies
NY19671101YA0400X
FL103081041C0700X
NY0784701041C0700X, 1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY078470OtherLICENSE
NY19671OtherCREDENTIAL
NY04029058Medicaid
FL10308OtherLICENSE
FL3233OtherCREDENTIAL
NYA400111965OtherMEDICARE PTAN