Provider Demographics
NPI:1912216193
Name:FERNANDEZ, MADELINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2610
Mailing Address - Country:US
Mailing Address - Phone:201-233-4050
Mailing Address - Fax:
Practice Address - Street 1:3051 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5721
Practice Address - Country:US
Practice Address - Phone:201-233-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009128103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool