Provider Demographics
NPI:1851744486
Name:FERNANDES, JUSTINIANO MANUEL
Entity Type:Individual
Prefix:
First Name:JUSTINIANO
Middle Name:MANUEL
Last Name:FERNANDES
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 1:89 DRAPER ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-1723
Mailing Address - Country:US
Mailing Address - Phone:617-820-3093
Mailing Address - Fax:617-506-5039
Practice Address - Street 1:895 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2902
Practice Address - Country:US
Practice Address - Phone:617-506-8188
Practice Address - Fax:617-506-5039
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker