Provider Demographics
NPI:1558511592
Name:FERNANDEZ, LILLIAN
Entity Type:Individual
Prefix:
First Name:LILLIAN
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 1:1156 N BROADWAY
Mailing Address - Street 2:ANDRUS CHILDREN'S CENTER
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1108
Mailing Address - Country:US
Mailing Address - Phone:914-965-3700
Mailing Address - Fax:
Practice Address - Street 1:35 DOCK ST
Practice Address - Street 2:ANDRUS CHILDREN'S CENTER
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-2733
Practice Address - Country:US
Practice Address - Phone:914-965-1109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013692103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285628552OtherAGENCY NPI
NYWVE061OtherAGENCY MEDICARE ID
NY00355940OtherAGENCY MEDICAID #
NYA400004791Medicare PIN