Provider Demographics
NPI:1609437649
Name:FERNANDEZ, ELYSE (MSW)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10707 MOORPARK ST APT 112
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-3603
Mailing Address - Country:US
Mailing Address - Phone:347-290-4968
Mailing Address - Fax:
Practice Address - Street 1:14545 SHERMAN CIR
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3087
Practice Address - Country:US
Practice Address - Phone:818-901-4854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW875111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical