Provider Demographics
NPI:1740811272
Name:FERNANDEZ, CARMEN LUISA
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LUISA
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-1918
Mailing Address - Country:US
Mailing Address - Phone:646-938-6544
Mailing Address - Fax:
Practice Address - Street 1:7000 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1022
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:718-886-8694
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Yes174400000XOther Service ProvidersSpecialist