Healthcare Provider Details

I. General information

NPI: 1013047653
Provider Name (Legal Business Name): LIZA MORAN FERNANDEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 HANDLEY RD STE 310
TYRONE GA
30290-2173
US

IV. Provider business mailing address

104 KIMMER RD
PEACHTREE CITY GA
30269-3633
US

V. Phone/Fax

Practice location:
  • Phone: 404-644-9244
  • Fax: 770-632-6351
Mailing address:
  • Phone: 404-644-9244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW002573
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: