=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255834701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. ODALYS FERNANDEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2018
-----------------------------------------------------
Last Update Date | 03/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8785 SW 165TH AVE STE 106D
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-391-2935
-----------------------------------------------------
Fax | 786-409-2019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8785 SW 165TH AVE STE 106D
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33193-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-391-2935
-----------------------------------------------------
Fax | 786-409-2019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------