Provider Demographics
NPI:1013122589
Name:FERNANDEZ, ROSE M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:M
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15423 SW 115TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6307
Mailing Address - Country:US
Mailing Address - Phone:305-323-7113
Mailing Address - Fax:305-386-5772
Practice Address - Street 1:15423 SW 115TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-6307
Practice Address - Country:US
Practice Address - Phone:305-323-7113
Practice Address - Fax:305-386-5772
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 68831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL590976373Medicaid