Provider Demographics
NPI:1255028015
Name:FERNANDEZ, MAYLIN (LMHC)
Entity type:Individual
Prefix:
First Name:MAYLIN
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21337 39TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2071
Mailing Address - Country:US
Mailing Address - Phone:818-395-8522
Mailing Address - Fax:
Practice Address - Street 1:20312 42ND AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1823
Practice Address - Country:US
Practice Address - Phone:818-395-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00940200101YP2500X
NY013073-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional