Provider Demographics
NPI:1982072815
Name:FERNANDES, CRISTIANE
Entity Type:Individual
Prefix:
First Name:CRISTIANE
Middle Name:
Last Name:FERNANDES
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 1:2789 ORTIZ AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7806
Mailing Address - Country:US
Mailing Address - Phone:239-791-1548
Mailing Address - Fax:
Practice Address - Street 1:2789 ORTIZ AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7806
Practice Address - Country:US
Practice Address - Phone:239-791-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2022-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
171M00000X
FL11887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator