Provider Demographics
NPI:1255637633
Name:FERNANDEZ, WILLY AMAURY (PHD)
Entity type:Individual
Prefix:DR
First Name:WILLY
Middle Name:AMAURY
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CALLE CARMEN MERCADO
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-5060
Mailing Address - Country:US
Mailing Address - Phone:787-528-7690
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL EMPORIUM SUITE 3A
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-528-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2648103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling