Provider Demographics
NPI:1548750821
Name:FERNANDEZ, EZEQUIEL LUIS
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
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 1:119 EAST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-1551
Mailing Address - Country:US
Mailing Address - Phone:413-657-0759
Mailing Address - Fax:
Practice Address - Street 1:119 EAST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-657-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-13
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker