Provider Demographics
NPI:1770179897
Name:FERNANDEZ, TINA LORENA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LORENA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27518 WHITMAN ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-4036
Mailing Address - Country:US
Mailing Address - Phone:510-228-6248
Mailing Address - Fax:
Practice Address - Street 1:27518 WHITMAN ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-4036
Practice Address - Country:US
Practice Address - Phone:510-228-6248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician