Healthcare Provider Details

I. General information

NPI: 1174301618
Provider Name (Legal Business Name): KANE RENE HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 SIR FRANCIS DRAKE BLVD
KENTFIELD CA
94904-1418
US

IV. Provider business mailing address

755 WILSON ST APT 208A
SANTA ROSA CA
95401-6277
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-6966
  • Fax:
Mailing address:
  • Phone: 832-412-5536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: