Provider Demographics
NPI:1003582412
Name:FERNANDEZ, EDWINA
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:
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 1:8411 SW 208TH TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3450
Mailing Address - Country:US
Mailing Address - Phone:786-322-9265
Mailing Address - Fax:
Practice Address - Street 1:8411 SW 208TH TER
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-3450
Practice Address - Country:US
Practice Address - Phone:786-322-9265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
FL106S00000X
FL1-23-64389103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty