Provider Demographics
NPI:1205808219
Name:FERNANDEZ, SHEBA M (LP PHD)
Entity type:Individual
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First Name:SHEBA
Middle Name:M
Last Name:FERNANDEZ
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Gender:F
Credentials:LP PHD
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Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:2345 ARIEL ST N
Practice Address - Street 2:MAIL STOP 13601A
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2248
Practice Address - Country:US
Practice Address - Phone:651-254-4793
Practice Address - Fax:651-254-0877
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2018-11-30
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Provider Licenses
StateLicense IDTaxonomies
MNLP3834103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN334513100Medicaid