Provider Demographics
NPI:1851721492
Name:FERNANDEZ GOMEZ, IRENE (MSED; PD; SAS)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:
Last Name:FERNANDEZ GOMEZ
Suffix:
Gender:F
Credentials:MSED; PD; SAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8605 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11369-1409
Mailing Address - Country:US
Mailing Address - Phone:917-692-2313
Mailing Address - Fax:
Practice Address - Street 1:8605 30TH AVE
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11369-1409
Practice Address - Country:US
Practice Address - Phone:917-692-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool