Healthcare Provider Details

I. General information

NPI: 1710306923
Provider Name (Legal Business Name): NORA EDITH HEREDIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 S BROOKHURST ROAD
FULLERTON CA
92833
US

IV. Provider business mailing address

8633 KNOTT AVE.
BUENA PARK CA
90620
US

V. Phone/Fax

Practice location:
  • Phone: 323-775-1046
  • Fax:
Mailing address:
  • Phone: 714-527-6561
  • Fax: 714-527-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: