Provider Demographics
NPI:1508376575
Name:FERNANDEZ, BETSY
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:
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 1:13205 SW 137TH AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2730 NW 30TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-6404
Practice Address - Country:US
Practice Address - Phone:786-328-9986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician