Provider Demographics
NPI:1205246881
Name:FERNANDEZ, LUIS (CASAC)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2976 NORTHERN BLVD
Mailing Address - Street 2:2ND FL
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-2822
Mailing Address - Country:US
Mailing Address - Phone:212-691-7554
Mailing Address - Fax:347-510-3457
Practice Address - Street 1:2976 NORTHERN BLVD
Practice Address - Street 2:2ND FL
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-2822
Practice Address - Country:US
Practice Address - Phone:212-691-7554
Practice Address - Fax:347-510-3457
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18448101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02740141Medicaid