1013047653 NPI number — MRS. LIZA MORAN FERNANDEZ LCSW

Table of content: MRS. LIZA MORAN FERNANDEZ LCSW (NPI 1013047653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013047653 NPI number — MRS. LIZA MORAN FERNANDEZ LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ
Provider First Name:
LIZA
Provider Middle Name:
MORAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013047653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 KIMMER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEACHTREE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30269-3633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-644-9244
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 HANDLEY RD STE 310
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYRONE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30290-2173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-644-9244
Provider Business Practice Location Address Fax Number:
770-632-6351
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CSW002573 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000847569B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com