Provider Demographics
NPI:1265678965
Name:FERNANDEZ, MARY ROSE (LMHC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ROSE
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ROSE
Other - Last Name:SEPTIMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:327 BEACH 19 STREET
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691
Mailing Address - Country:US
Mailing Address - Phone:718-474-2478
Mailing Address - Fax:
Practice Address - Street 1:9502 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1317
Practice Address - Country:US
Practice Address - Phone:718-474-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-30
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004349-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health