Provider Demographics
NPI:1376822437
Name:FERNANDEZ, BISMAK (BA)
Entity Type:Individual
Prefix:
First Name:BISMAK
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10149 SW 223RD TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1570
Mailing Address - Country:US
Mailing Address - Phone:786-537-4294
Mailing Address - Fax:
Practice Address - Street 1:7715 NW 48TH ST
Practice Address - Street 2:350B
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-5455
Practice Address - Country:US
Practice Address - Phone:305-846-9807
Practice Address - Fax:305-846-9711
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL263083308103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst