Provider Demographics
NPI:1710570502
Name:FERNANDEZ, JOHANDER
Entity Type:Individual
Prefix:
First Name:JOHANDER
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 1:8160 GENEVA CT APT 311
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7925 NW 12TH ST STE 130
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1820
Practice Address - Country:US
Practice Address - Phone:786-870-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician