Basic Information
| Provider Information | |||||||||
| NPI: | 1043254196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | ROSA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11031 NE 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331617182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053986100 | ||||||||
| FaxNumber: | 3057574465 | ||||||||
| Practice Location | |||||||||
| Address1: | 17567 S DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331575435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862939544 | ||||||||
| FaxNumber: | 7862939594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 761424100 | 05 | FL | MEDICAID |