Provider Demographics
NPI:1538940614
Name:SOARES CAMPOS FERNANDES, LIDIANE
Entity type:Individual
Prefix:
First Name:LIDIANE
Middle Name:
Last Name:SOARES CAMPOS FERNANDES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2666 STATE ST UNIT A3
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-2232
Mailing Address - Country:US
Mailing Address - Phone:866-681-5584
Mailing Address - Fax:
Practice Address - Street 1:2666 STATE ST UNIT A3
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-2232
Practice Address - Country:US
Practice Address - Phone:866-681-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty