Healthcare Provider Details

I. General information

NPI: 1083026355
Provider Name (Legal Business Name): ANGELICA FERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELICA PORRAS

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 SAN JACINTO RIVER RD STE 107
LAKE ELSINORE CA
92530-4400
US

IV. Provider business mailing address

265 SAN JACINTO RIVER RD STE 107
LAKE ELSINORE CA
92530-4400
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-9243
  • Fax:
Mailing address:
  • Phone: 951-674-9243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number130458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: