Provider Demographics
NPI:1376062851
Name:FERNANDEZ, ROSITA M
Entity Type:Individual
Prefix:
First Name:ROSITA
Middle Name:M
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 MARGARET CT
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-2330
Mailing Address - Country:US
Mailing Address - Phone:812-201-3912
Mailing Address - Fax:
Practice Address - Street 1:318 MARGARET CT
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2330
Practice Address - Country:US
Practice Address - Phone:812-201-3912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3535103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376062851Medicaid
IN300007198INMedicaid