Provider Demographics
NPI:1417411703
Name:FERNANDES, LAVISHA NITA (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LAVISHA
Middle Name:NITA
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 GRAFTON LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-7009
Mailing Address - Country:US
Mailing Address - Phone:630-687-8963
Mailing Address - Fax:
Practice Address - Street 1:3209 GRAFTON LN
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-7009
Practice Address - Country:US
Practice Address - Phone:630-687-8963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-18-34066103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst