Provider Demographics
NPI:1558917401
Name:FERNANDEZ, MAIRA ALEJANDRA (RADT 1)
Entity Type:Individual
Prefix:
First Name:MAIRA
Middle Name:ALEJANDRA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:RADT 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NAPA VALLEJO HWY
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6234
Mailing Address - Country:US
Mailing Address - Phone:707-255-8001
Mailing Address - Fax:
Practice Address - Street 1:2425 KIESS BARN PL
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2563
Practice Address - Country:US
Practice Address - Phone:707-307-2748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)