=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255131819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FERNANDEZ THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2025
-----------------------------------------------------
Last Update Date | 03/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3015 N ASHLAND AVE APT 4S
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-271-9587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3015 N ASHLAND AVE APT 4S
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-271-9587
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | KATHERINE G FERNANDEZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 847-271-9587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------