Healthcare Provider Details

I. General information

NPI: 1568887974
Provider Name (Legal Business Name): JUAN FERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 W 56TH ST SUITE 15-16
HIALEAH FL
33016-2601
US

IV. Provider business mailing address

1828 SW 182ND AVE
MIRAMAR FL
33029-5223
US

V. Phone/Fax

Practice location:
  • Phone: 305-557-1555
  • Fax: 305-397-2847
Mailing address:
  • Phone: 954-297-3678
  • Fax: 305-397-2847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-19-9742
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: