Provider Demographics
NPI:1831716612
Name:CERVANTES FERNANDEZ, JOSE GUILLERMO
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:GUILLERMO
Last Name:CERVANTES FERNANDEZ
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 1:1930 NE 185TH TER
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4308
Mailing Address - Country:US
Mailing Address - Phone:786-523-3249
Mailing Address - Fax:
Practice Address - Street 1:1930 NE 185TH TER
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33179-4308
Practice Address - Country:US
Practice Address - Phone:786-523-3249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-42554103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst