Provider Demographics
NPI:1528363421
Name:FERNANDEZ, MARIEL CREMONIE (BCBA)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:CREMONIE
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MARIEL
Other - Middle Name:CASSANDRA
Other - Last Name:CREMONIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:10503 METRIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243
Mailing Address - Country:US
Mailing Address - Phone:972-644-2076
Mailing Address - Fax:972-644-5650
Practice Address - Street 1:10503 METRIC DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5514
Practice Address - Country:US
Practice Address - Phone:972-644-2076
Practice Address - Fax:972-644-5650
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-04-2082103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-04-2082OtherBCBA
TX1-04-2082OtherMS, BCBA