Healthcare Provider Details

I. General information

NPI: 1629833686
Provider Name (Legal Business Name): JOHANNA TERESA HERNANDEZ MATEO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11287 WASHINGTON BLVD
CULVER CITY CA
90230-4615
US

IV. Provider business mailing address

2901 S SEPULVEDA BLVD APT 158
LOS ANGELES CA
90064-3941
US

V. Phone/Fax

Practice location:
  • Phone: 323-695-6134
  • Fax:
Mailing address:
  • Phone: 323-695-6134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: