Healthcare Provider Details

I. General information

NPI: 1407459258
Provider Name (Legal Business Name): MANDY FERNANDEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 E CLARK ST STE 330
POCATELLO ID
83201-3357
US

IV. Provider business mailing address

195 CHARLES PL
POCATELLO ID
83201-3248
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-9081
  • Fax:
Mailing address:
  • Phone: 208-252-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-39280
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8861300
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: