Provider Demographics
NPI:1740012160
Name:FERNANDEZ GUTIERREZ, LIDIER A
Entity type:Individual
Prefix:
First Name:LIDIER
Middle Name:A
Last Name:FERNANDEZ GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 NE 29TH ST APT 1210
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-5239
Mailing Address - Country:US
Mailing Address - Phone:786-970-7637
Mailing Address - Fax:
Practice Address - Street 1:180 NE 29TH ST APT 1210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-5239
Practice Address - Country:US
Practice Address - Phone:786-970-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24357775106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician