Basic Information
| Provider Information | |||||||||
| NPI: | 1255007464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 AVENUE 64 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232542274 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5400 E OLYMPIC BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900225147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238699255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2021 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | AMFT127889 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.