MEDICARE: MRS. NICOLE ARLYN FERNANDEZ LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	166.001120	IL

General Provider Information

NPI Number	:	1881133601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE ARLYN FERNANDEZ LMFT

Provider Business Mailing Address
First Line	:	5126 W AGATITE AVE
Second Line	:	# 1
City	:	CHICAGO
State	:	IL
Zip	:	60630-3702
Country	:	US
Telephone Number	:	773-936-5844
Fax Number	:

Provider Business Practice Location Address
First Line	:	5126 W AGATITE AVE
Second Line	:	# 1
City	:	CHICAGO
State	:	IL
Zip	:	60630-3702
Country	:	US
Telephone Number	:	773-936-5844
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2017
Last Update Date	:	02/13/2017

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