Provider Demographics
NPI:1346376563
Name:FERNANDEZ, ALEXIS NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 PACIFIC HWY UNIT 2806
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8466
Mailing Address - Country:US
Mailing Address - Phone:310-970-4744
Mailing Address - Fax:
Practice Address - Street 1:900 BROADWAY STE 910
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1249
Practice Address - Country:US
Practice Address - Phone:310-970-4744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001-084101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health