Healthcare Provider Details

I. General information

NPI: 1568743284
Provider Name (Legal Business Name): ELIZABETH ANDREA FERNANDEZ CD (DONA), LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 FAIR ST STE 28
KINGSTON NY
12401-3882
US

IV. Provider business mailing address

275 FAIR ST STE 28
KINGSTON NY
12401-3882
US

V. Phone/Fax

Practice location:
  • Phone: 845-706-9385
  • Fax: 845-338-2540
Mailing address:
  • Phone: 845-706-9385
  • Fax: 845-338-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number081408-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number08-0911
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number3965
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: