Provider Demographics
NPI:1255648382
Name:FERNANDEZ, LAETITIA B (MS PSY)
Entity type:Individual
Prefix:
First Name:LAETITIA
Middle Name:B
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MS PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3083
Mailing Address - Country:US
Mailing Address - Phone:772-257-5264
Mailing Address - Fax:772-257-5265
Practice Address - Street 1:1945 22ND AVE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3083
Practice Address - Country:US
Practice Address - Phone:772-257-5264
Practice Address - Fax:772-257-5265
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH9028101YM0800X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002649800Medicaid