Provider Demographics
NPI:1508431057
Name:FERNANDEZ, JOSE LUIS
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1881 NW 123RD AVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3825
Practice Address - Country:US
Practice Address - Phone:954-589-5697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-121982106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician