Healthcare Provider Details

I. General information

NPI: 1881060473
Provider Name (Legal Business Name): MISS ELSIE CORAL HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

IV. Provider business mailing address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

V. Phone/Fax

Practice location:
  • Phone: 562-485-1159
  • Fax:
Mailing address:
  • Phone: 562-595-1159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number81699
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number98493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: