Provider Demographics
NPI:1750922837
Name:FERNANDEZ, LIDA EUDALY (OT)
Entity type:Individual
Prefix:
First Name:LIDA
Middle Name:EUDALY
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 VINE ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1817
Mailing Address - Country:US
Mailing Address - Phone:908-906-0978
Mailing Address - Fax:
Practice Address - Street 1:329 VINE ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-1817
Practice Address - Country:US
Practice Address - Phone:908-906-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00354400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist