Provider Demographics
NPI:1407459258
Name:FERNANDEZ, MANDY (LMSW)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 CHARLES PL
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3248
Mailing Address - Country:US
Mailing Address - Phone:208-252-1764
Mailing Address - Fax:
Practice Address - Street 1:1777 E CLARK ST STE 330
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3357
Practice Address - Country:US
Practice Address - Phone:208-478-9081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-39280104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker