Provider Demographics
NPI:1720023492
Name:FERNANDEZ, MARY EDDY (MFCC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:EDDY
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MFCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17501 IRVINE BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3101
Mailing Address - Country:US
Mailing Address - Phone:714-544-9255
Mailing Address - Fax:
Practice Address - Street 1:17501 IRVINE BLVD
Practice Address - Street 2:STE 11
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3103
Practice Address - Country:US
Practice Address - Phone:714-544-9255
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC21380101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health