Healthcare Provider Details

I. General information

NPI: 1558487637
Provider Name (Legal Business Name): SONIA C. FERNANDEZ M.A., L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD RM 310
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

24536 WALTER DR
BROWNSTOWN MI
48134-9156
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7705
  • Fax: 734-785-7733
Mailing address:
  • Phone: 734-782-1573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401003534
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: