Provider Demographics
NPI:1467998237
Name:HAZEL-FERNANDEZ, LESLIE ANN (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE ANN
Middle Name:
Last Name:HAZEL-FERNANDEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BEACH 26TH ST
Mailing Address - Street 2:APT 805
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2238
Mailing Address - Country:US
Mailing Address - Phone:305-812-2902
Mailing Address - Fax:305-812-2902
Practice Address - Street 1:120 BEACH 26TH ST
Practice Address - Street 2:APT 805
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2238
Practice Address - Country:US
Practice Address - Phone:305-812-2902
Practice Address - Fax:305-812-2902
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68021989103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical