Provider Demographics
NPI:1508614868
Name:FERNANDEZ, EDGARDO (LCADC)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 HICKORY CORNER RD
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-2415
Mailing Address - Country:US
Mailing Address - Phone:732-690-4616
Mailing Address - Fax:732-289-6009
Practice Address - Street 1:107 CEDAR GROVE LN STE 103E
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-4719
Practice Address - Country:US
Practice Address - Phone:732-289-6008
Practice Address - Fax:732-289-6009
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC0162000101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)