Provider Demographics
NPI:1851519599
Name:FERNANDEZ, RICHARD C (MS,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:MS,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 510174
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-0174
Mailing Address - Country:US
Mailing Address - Phone:305-393-3948
Mailing Address - Fax:321-574-8665
Practice Address - Street 1:401 OCEAN AVE
Practice Address - Street 2:SUITE 201A
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2558
Practice Address - Country:US
Practice Address - Phone:305-393-3948
Practice Address - Fax:321-574-8665
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3853235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA3853OtherPROFESSIONAL LIC