Provider Demographics
NPI:1568887974
Name:FERNANDEZ, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
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 1:1828 SW 182ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5223
Mailing Address - Country:US
Mailing Address - Phone:954-297-3678
Mailing Address - Fax:305-397-2847
Practice Address - Street 1:2050 W 56TH ST
Practice Address - Street 2:SUITE 15-16
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-2601
Practice Address - Country:US
Practice Address - Phone:305-557-1555
Practice Address - Fax:305-397-2847
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
FL0-19-9742106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist